The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis

Women's experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study

BACKGROUND

Anxiety in pregnancy and postnatally is highly prevalent but under-recognized. To identify perinatal anxiety, assessment tools must be acceptable to women who are pregnant or postnatal.

METHODS

A qualitative study of women's experiences of anxiety and mental health assessment during pregnancy and after birth and views on the acceptability of perinatal anxiety assessment. Semi-structured interviews were conducted with 41 pregnant or postnatal women. Results were analysed using Sekhon et al.'s acceptability framework, as well as inductive coding of new or emergent themes.

RESULTS

Women's perceptions of routine assessment for perinatal anxiety were generally favourable. Most participants thought assessment was needed and that the benefits outweighed potential negative impacts, such as unnecessary referrals to specialist services. Six themes were identified of: (1) Raising awareness; (2) Improving support; (3) Surveillance and stigma; (4) Gatekeeping; (5) Personalized care and (6) Trust. Assessment was seen as a tool for raising awareness about mental health during the perinatal period and a mechanism for normalizing discussions about mental health more generally. However, views on questionnaire assessments themselves were mixed, with some participants feeling they could become an administrative 'tick box' exercise that depersonalizes care and does not provide a space to discuss mental health problems.

CONCLUSION

Routine assessment of perinatal anxiety was generally viewed as positive and acceptable; however, this was qualified by the extent to which it was informed and personalized as a process. Approaches to assessment should ideally be flexible, tailored across the perinatal period and embedded in continuity of care.

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents

BACKGROUND

Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood.

OBJECTIVES

We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care.

METHODS

B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health.

IMPLICATIONS

If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Promoting mental wellbeing in pregnant women living in Pakistan with the Safe Motherhood-Accessible Resilience Training (SM-ART) intervention: a randomized controlled trial

BACKGROUND

The negative impact of adverse perinatal mental health extends beyond the mother and child; therefore, it is essential to make an early intervention for the management of mental illness during pregnancy. Resilience-building interventions are demonstrated to reduce depression and anxiety among expectant mothers, yet research in this field is limited. This study aims to examine the effect of the 'Safe Motherhood-Accessible Resilience Training (SM-ART)' on resilience, marital adjustment, depression, and pregnancy-related anxiety in a sample of pregnant women in Karachi, Pakistan.

METHOD

In this single-blinded block randomized controlled study, 200 pregnant women were recruited and randomly assigned to either an intervention or a control group using computer-generated randomization and opaque sealed envelopes. The intervention group received the SM-ART intervention consisting of six, weekly sessions ranging from 60 to 90 min. Outcomes (Resilience, depression, pregnancy-related anxiety and marital harmony) were assessed through validated instruments at baseline and after six weeks of both intervention and control groups.

RESULTS

The results revealed a significant increase in mean resilience scores (Difference:6.91, Effect size: 0.48, p-value < 0.05) and a decrease in depressive symptoms (Difference: -2.12, Effect size: 0.21, p-value < 0.05) in the intervention group compared to the control group. However, no significant change was observed in anxiety and marital adjustment scores.

CONCLUSION

The SM-ART intervention has the potential to boost resilience scores and decrease depressive symptoms in pregnant women and offers a promising intervention to improve maternal psychological health.

TRIAL REGISTRATION

NCT04694261, Date of first trial registration: 05/01/2021.

The Stirling Antenatal Anxiety Scale (SAAS): Turkish validity and reliability study

AIMS

To examine the psychometric properties of the Stirling Antenatal Anxiety Scale (SAAS), developed by Sinesi et al., which assesses the level of anxiety of pregnant women in the prenatal period, in the Turkish culture, and to conduct a validity and reliability study.

METHODS

This study had a methodological approach, with a cross-sectional and descriptive research design. Reporting was in accordance with the STROBE checklist. The sample included 160 pregnant women who were followed up in the maternity outpatient clinics of a public hospital and a private hospital in Istanbul. Data were collected face-to-face using a personal information form, the Turkish version of the SAAS, and the Generalized Anxiety Disorder-7 scale between June and August 2023. In the data analysis, validity analyses were performed with content and construct validity and multiple fit indices for confirmatory factor analysis. Item-total score analysis was conducted using Cronbach's alpha coefficient and Pearson's correlation analysis to assess reliability. Descriptive and reliability analyses were undertaken using SPSS v.28.0.1.0, and validity analyses were performed using SPSS AMOS v.26.0.0.0.

FINDINGS

Based on expert opinions on the items in the Turkish version of the SAAS, the content validity ratio was 0.96. The decision was made to exclude Item 9 from the Turkish version because the item factor load was low. The Turkish version had a single factor, as did the original version. The Cronbach alpha coefficient was 0.87, so the Turkish version was determined to have high reliability.

CONCLUSION

The Turkish version of the SAAS, originally produced in English, has high levels of validity and reliability. In addition, it is short and easy to apply in clinical and research settings. As such, the Turkish version of the SAAS is recommended for use to evaluate the level of anxiety in pregnant women.

Prenatal antidepressant use and risk of congenital malformations: A population-based cohort study

Previous studies examining antidepressants and congenital-malformations were primarily conducted in western countries, and many were constrained by important methodological limitations. This population-based study identified 465,069 women (including 1,705 redeemed ≥1 prescription of antidepressants during first-trimester) aged 15-50 years who delivered their first and singleton child between 2003 and 2018 in a predominantly-Chinese population in Hong Kong, using territory-wide medical-record database of public-healthcare services, and employed propensity-score fine-stratification-weighted logistic-regression analyses to evaluate risk of any major and organ/system-specific congenital-malformations following first-trimester exposure to antidepressants. Major malformation overall was not associated with any antidepressant (weighted-odds-ratio wOR, 0.88 [95 %CI, 0.44-1.76]), specific drug-class, or individual antidepressants. Exposure to any antidepressant was associated with increased risk of cardiac (wOR, 1.82 [95 %CI, 1.07-3.12]) and respiratory anomalies (wOR,4.11 [95 %CI, 1.61-10.45]). Exposure to selective-serotonin-reuptake-inhibitors (SSRI) and multiple-AD-classes were associated with respiratory and cardiac anomalies, respectively. However, these identified associations were not consistently affirmed across sensitivity analyses, precluding firm conclusion. Observed associations of specific cardiac defects with serotonin-norepinephrine-reuptake-inhibitors (SNRI), tricyclic-antidepressants (TCA) and multiple-AD-classes were noted with wide confidence-intervals, suggesting imprecise estimation. Overall, our findings suggest that first-trimester antidepressant exposure was not robustly associated with increased risk of congenital-malformations. Further research clarifying comparative safety of individual antidepressants on specific malformations is warranted.

The Prevalence of Maternal Depression and Anxiety Beyond 1 Year Postpartum: A Systematic Review

BACKGROUND

Maternal depression and anxiety occurring beyond the 1-year postpartum period can lead to significant suffering for both mother and child. This study aimed to systematically review and synthesize studies reporting the prevalence and incidence of maternal depression and anxiety beyond 1 year post-childbirth.

METHODS

A systematic literature review of the PsycINFO, Medline, and Embase databases identified studies reporting on the prevalence and/or incidence of depression and/or anxiety among mothers between 1 and 12 years post-childbirth. The quality of the included studies was assessed. Findings were synthesized qualitatively.

RESULTS

Twenty-one studies were identified that met the inclusion and exclusion criteria. All studies reported the prevalence of depression, with 31 estimates ranging from 6.6% at 3 to 11 years post-childbirth to 41.4% at 3 to 4 years post-childbirth. Five of these studies also reported the prevalence of depression in subgroups (e.g., ethnic origin, income, marital status). Four studies reported the prevalence of anxiety, with nine estimates ranging from 3.7% at 5 years post-childbirth to 37.0% at 3 to 4 years post-childbirth. Only one study reported incidence. The quality of the included studies was variable, with most studies scoring above 7/9.

CONCLUSION

Maternal anxiety and depression remain prevalent beyond the first year postpartum, particularly in marginalized subgroups. Current observational studies lack consistency and produce highly variable prevalence rates, calling for more standardized measures of depression and anxiety. Clinical practice and research should consider the prevalence of maternal anxiety and depression beyond this period.

Are virtual services equivalent for mood, anxiety, and bonding? examining a perinatal intensive outpatient program

PURPOSE

Perinatal Intensive Outpatient Programs (IOPs) address severe perinatal mood and anxiety disorders (PMADs) and mother-infant relationship concerns. Given the impact of PMADs on mothers and infants, rapid transitions to virtual services (telehealth) amid COVID-19, and service expansions to populations in need, it is critical to evaluate how effectively virtual and in-person perinatal IOP services treat PMADs and mother-infant bonding.

METHODS

This quality-improvement record review examined patient records (n = 361) for a perinatal IOP from May 2016 to July 2023, amid multiple transitions between in-person and virtual services related to COVID-19, influenza, and respiratory syncytial virus. Patients in the completed measures sample (n = 115) completed depression (EPDS), anxiety (GAD-7, PASS), and mother-infant bonding (PBQ) measures over the first 3 weeks of treatment. Patients also anonymously provided program satisfaction ratings and qualitative feedback.

RESULTS

While anxiety and depression symptoms improved similarly across service settings, mother-baby bonding only significantly improved with in-person treatment. Patient symptom outcomes also differed by public/private insurance, race, and number of children. Patients reported high service ratings and overall satisfaction, and available feedback indicates some preference for in-person services.

CONCLUSION

As perinatal mental health services and IOPs continue to expand, virtual services can similarly address anxiety and depression symptoms and help to reach in-need populations. However, for perinatal IOPs, the core treatment target of mother-infant bonding may be uniquely addressed via in-person services.

Effects of digital health interventions on the psychological outcomes of perinatal women: umbrella review of systematic reviews and meta-analyses

Evidence about the effects of digital health interventions (DHIs) on the psychological outcomes of perinatal women is increasing but remains inconsistent. An umbrella review was conducted to (1) assess the effect of DHIs on depressive, anxiety and stress symptoms and (2) compare the effects of DHIs on different digital platforms and population natures. Ten databases were searched from inception until December 23, 2022. The Hartung-Knapp-Sidik-Jonkman random-effects meta-analyses were utilised. Methodological quality was evaluated using the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2). Twenty-four systematic reviews with 41 meta-analyses involving 45,509 perinatal women from 264 primary studies were included. The credibility of the evidence of meta-analyses was rated as highly suggestive (4.88%), suggestive (26.83%), weak (51.22%) or non-significant (17.07%) according to AMSTAR-2. Our findings suggest that DHIs are beneficial for reducing stress symptoms. However, conflicting effects were found on anxiety symptoms. Subgroup and meta-regression analyses suggested that DHIs effectively improve depressive symptoms in postnatal women, and DHIs using the website platform are highly effective in stress reduction. DHIs can be implemented adjuvant to usual obstetric care to improve depressive and stress symptoms. Additional well-designed RCTs with long-term follow-up are warranted.

Investigation and Analysis of Emotional State and Oxytocin Level in Patients with Postpartum Depression

BACKGROUND

Postpartum depression (PPD) is a common mental disorder in postpartum women, negatively impacting physical and mental health. Correlation analysis can predict the relationship between variables. By detecting the abnormal level of oxytocin, clinicians can timely know the emotional states of parturients to guide clinical practice. This study aimed to investigate the relationship between emotional states and oxytocin (OT) levels in patients with PPD.

MATERIALS AND METHODS

The medical records of 166 PPD patients admitted to Cangzhou Central Hospital from May 2020 to March 2023 were retrospectively analyzed. After excluding 9 patients who did not meet the inclusion criteria, the remaining 157 patients were included in this study. The 7-item Generalized Anxiety Disorder Scale and Patient Health Questionaire-9 items were used to evaluate the emotional states of 157 patients, and the included subjects were grouped according to the results of the scale. The serum OT levels of patients was measured, and the relationship between the OT levels and emotional states was analyzed.

RESULTS

In this study, 75 patients were included in the mild anxiety group, and 82 patients were included in the moderate and severe anxiety group. Seventy-nine patients were selected as the mild depression group, and 78 patients were included in the moderate and severe depression group. The mild anxiety group had a higher OT level than the moderate and severe anxiety group (Z = -10.121, p < 0.001). The mild depression group had a higher OT level than the moderate and severe depression group (Z = -9.758, p < 0.001). OT level was negatively correlated with anxiety and depression scores (r = -0.676, r = -0.665, p < 0.001).

CONCLUSION

There is a specific relationship between the emotional states of PPD patients and the OT levels in the body, and active clinical management strategies need to be implemented.

Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan

OBJECTIVE

The prevalence of postnatal anxiety is high among women during the first year of childbirth globally. Rates are higher in low and middle-income countries (LMICs), that is, 24%. Existing literature on maternal mood and its impact on child development has largely focused on postnatal depression. Postnatal anxiety has been recognised to have significant independent effects similar to those of postnatal depression, including negative effects on various aspects of maternal well-being including quality of life, parent-child interaction and child development. The evidence exploring lived experiences of postnatal anxiety is limited from LMICs. This study explored the lived experiences of anxiety in postnatal mothers in Pakistan.

DESIGN

A phenomenological approach was used for this qualitative study. The audio-recorded interviews were transcribed and analysed using the process of thematic analysis.

SETTINGS

The study was conducted in two community settings in Karachi, Pakistan; the Bin Qasim and Gadap town.

PARTICIPANTS

Women who were 18 years of age or older, had a live childbirth within the previous 12 months and had a score of 10 or higher on the Generalised Anxiety Disorder-7.

RESULTS

In-depth, one-to-one interviews were conducted with 10 participants. The qualitative data comprised of three themes. Theme one: Factors perceived to be associated with postnatal anxiety, Theme two: The perceived impact of postnatal anxiety and Theme three: Support needs. The first theme was further subdivided into two subthemes, that is, Mothers' perception of navigating domestic responsibilities and sociocultural norms of motherhood and financial constraints.

CONCLUSION

Despite the high prevalence of postnatal anxiety in LMICs there is not any published evidence on exploring this phenomenon through in-depth research in Pakistan. Understanding the lived experiences will help health professionals to identify women at risk of developing postnatal anxiety and to develop effective culturally appropriate interventions for women with anxiety during this postnatal period.

Investigating heart rate variability measures during pregnancy as predictors of postpartum depression and anxiety: an exploratory study

Perinatal affective disorders are common, but standard screening measures reliant on subjective self-reports might not be sufficient to identify pregnant women at-risk for developing postpartum depression and anxiety. Lower heart rate variability (HRV) has been shown to be associated with affective disorders. The current exploratory study aimed to evaluate the predictive utility of late pregnancy HRV measurements of postpartum affective symptoms. A subset of participants from the BASIC study (Uppsala, Sweden) took part in a sub-study at pregnancy week 38 where HRV was measured before and after a mild stressor (n = 122). Outcome measures were 6-week postpartum depression and anxiety symptoms as quantified by the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Anxiety Inventory (BAI). In total, 112 women were included in a depression outcome analysis and 106 women were included in an anxiety outcome analysis. Group comparisons indicated that lower pregnancy HRV was associated with depressive or anxious symptomatology at 6 weeks postpartum. Elastic net logistic regression analyses indicated that HRV indices alone were not predictive of postpartum depression or anxiety outcomes, but HRV indices were selected as predictors in a combined model with background and pregnancy variables. ROC curves for the combined models gave an area under the curve (AUC) of 0.93 for the depression outcome and an AUC of 0.83 for the anxiety outcome. HRV indices predictive of postpartum depression generally differed from those predictive of postpartum anxiety. HRV indices did not significantly improve prediction models comprised of psychological measures only in women with pregnancy depression or anxiety.

Anxiety, prenatal distress, and resilience during the first trimester of gestation

OBJECTIVE

To describe and analyze the relationship between pregnancy-related anxiety, prenatal distress, and individual resilience in pregnant women during the first trimester of pregnancy and compare it with the obstetric variable of parity.

METHOD

Quantitative, descriptive, cross-sectional study using non-probabilistic circumstantial sampling. A total of 144 women participated. The Prenatal Distress Questionnaire, the Resilience Scale, and the Pregnancy-Related Anxiety Questionnaire were used. A descriptive analysis with measures of central tendency was performed, and the reliability of the instruments was assessed.

RESULTS

The average age was 33.57 years. 58.3% were multiparous and 41.7% primiparous. Anxiety was found in 21.5% and very high levels of resilience in 54.9%. Primiparous women showed higher levels of worry about the future and fear of childbirth than multiparous women. Pregnant women with high resilience showed lower levels of anxiety and stress.

CONCLUSION

Pregnant women with higher levels of resilience show less anxiety and stress during the first trimester of pregnancy. Primiparous women show more anxiety and stress than multiparous women.

Mental Health Treatment Rates During Pregnancy and Post Partum in US Military Service Members

Importance

Although new parents' mental health is known to decline, less is known about changes in therapy attendance, especially among military service members.

Objective

To investigate changes in therapy attendance among new parents and by parental leave length.

Design, Setting, and Participants

This cohort study of US Army and Navy service members from January 1, 2013, to December 31, 2019, compared parents' monthly therapy attendance with matched nonparents' across childbirth and compared mothers' weekly therapy attendance before vs after returning to work. Eligible monthly sample members included service members with first births from January 1, 2014, to December 31, 2017, and 12 months of data before to 24 months after birth and nonparents with 36 months of data. Eligible weekly sample members included mothers with first births from January 1, 2013, to June 30, 2019, and data from 12 months before to 6 months after birth and nonparents with 18 months of data. Data analysis was performed from July 1, 2023, to January 15, 2024.

Exposure

Those exposed to parenthood had no prior children, acquired a dependent younger than 1 year, and, for mothers, had an inpatient birth. Unexposed matches did not add a dependent younger than 1 year.

Main Outcomes and Measures

Monthly counts of mental health therapy sessions and any therapy sessions (weekly).

Results

The monthly sample included 15 554 193 person-month observations, representing 321 200 parents and matches, including 10 193 mothers (3.2%; mean [SD] age, 25.0 [4.9] years), 50 865 nonmother matches (15.8%; mean [SD] age, 25.0 [5.0] years), 43 365 fathers (13.5%; mean [SD] age, 26.4 [4.8] years), and 216 777 nonfather matches (67.5%; mean [SD] age, 26.4 [4.8] years). The weekly sample included 17 464 mothers. Mothers went to 0.0712 fewer sessions at 1 month post partum (95% CI, -0.0846 to -0.0579) compared with 10 months before birth. Fathers went to 0.0154 fewer sessions in the month of birth (95% CI, -0.0194 to -0.0114) compared with 10 months before. Parents with preexisting treatment needs had larger decreases in treatment. Weekly therapy attendance increased by 0.555 percentage points (95% CI, 0.257-0.852) when mothers returned to work from 6 weeks of leave and 0.953 percentage points (95% CI, 0.610-1.297) after 12 weeks of leave.

Conclusions and Relevance

In this cohort study of new parents, therapy attendance decreased around childbirth, especially among parents with prior mental health needs and mothers with longer maternity leaves. These findings suggest that more accessible treatment, including home visits or telehealth appointments, is needed.

Self-Reported Causes of Psychological Distress Among Czech Perinatal Women

BACKGROUND

Various risk factors to perinatal mental health disorders have been described; however, there is a dearth of data on the perspectives of women themselves regarding what increases the risk of psychological distress. This qualitative study explores women's perceptions of factors that increase the risk of perinatal psychological distress.

AIM

The aim of this study was to elucidate women's perceptions of factors that increase the risk of perinatal psychological distress.

METHODS

A qualitative design with an exploratory and descriptive approach is used. Women (N = 188) aged 18 to 45 years who self-report experiencing perinatal psychological distress complete an online survey.

RESULTS

Perceived causes of perinatal psychological distress include: adverse experiences with childbirth and/or breastfeeding, negative attitudes of people close to the participant, financial and social challenges, health challenges, staff behavior in a maternity hospital, a challenging baby, family circumstances, and the new role as mother.

CONCLUSION

Women's perceived causes of perinatal psychological distress may allow for women-centered innovations in perinatal mental health care. The results highlight the need to train maternity staff regarding perinatal mental health and communication. These findings can serve as important guidelines on women-centered planning of innovations of perinatal mental health care. Interventions need to focus on the role of partners and others close to women so as to support the women during the perinatal period.

Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.

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.

Post-Traumatic Stress Disorder in Brazilian Pregnant Women at the Beginning of the Coronavirus Disease Pandemic

OBJECTIVE

Analyze the presence of PTSD symptoms and their risk among the pregnant women during the COVID-19 pandemic.

METHODS

This is a cross-sectional study of pregnant women that received receiving prenatal care at two university hospitals in São Paulo, Brazil, during the COVID-19 pandemic, from April to June 2020. The sociodemographic and health data of the participants and their exposure to individuals suspected or confirmed to have COVID-19 were evaluated. The Impact of Event Scale-Revised and the State-Trait Anxiety Inventory were used to assess PTSD and anxiety symptoms, respectively.

RESULTS

A total of 149 pregnant women were included in this study. The risk of PTSD among the participants was 55.1%. The independent risk factors for PTSD were state anxiety (ORadj = 2.6), trait anxiety (ORadj = 10.7), changes in routine due to the pandemic (ORadj = 4.7) and contact with a confirmed case of COVID-19 person (ORadj = 7.1).

CONCLUSIONS

The COVID-19 pandemic had a significant negative impact on the mental health of pregnant women, more than half of the participants of the present study showed a risk of PTSD, exacerbated by anxiety symptoms and exposure to individuals with a confirmed case of COVID-19.

Assessment of perinatal anxiety: diagnostic accuracy of five measures

BACKGROUND

Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately.

AIMS

To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective).

METHOD

We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI).

RESULTS

The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure.

CONCLUSIONS

This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.

The association between the number of pregnancies and depressive symptoms: A population-based study

BACKGROUND

Depression is a psychosomatic disorder that affects reproductive health. The number of pregnancies is an important indicator of reproductive health. Multiple pregnancies and births may aggravate the risk of depression in females. However, the evidence of the connection between the number of pregnancies and depression is unclear. We aimed to investigate the relationship between the number of pregnancies and depressive symptoms.

METHODS

We used the National Health and Nutrition Examination Survey (NHANES) data with a total of 17,216 women from 2005 to 2020. The number of pregnancies obtained from the self-report questionnaire. Depressive symptoms were measured by the nine-item patient health questionnaire (PHQ-9). Multivariate logistic regression models were used to examine the risk factors of depression. The restricted cubic spline (RCS) was applied to explore the nonlinear relationship. In addition, subgroup analysis was used to support the accuracy of our findings.

RESULTS

We found that the number of pregnancies is positively associated with the prevalence of depression. According to the multivariable logistic regression analysis, pregnant women was 1.52-fold higher than the normal group to experience depression in the fully-adjusted model. No interaction between number of pregnancies and covariates in subgroups.

LIMITATIONS

This study was cross-sectional, which limits its ability to draw conclusions about the causal relationship between the number of pregnancies and depression.

CONCLUSION

In the United States, the number of pregnancies was positively associated with the prevalence of depression. It is critical to register the number of pregnancies for monitoring depressive symptoms.

Obsessive-compulsive disorder symptoms and intrusive thoughts in the postpartum period: Associations with trauma exposure and PTSD symptoms

In a community sample of trauma-exposed postpartum individuals (N = 167; mean age = 30, 90% White; 61.7% completed bachelor's degree or higher) longitudinally completed self-report measures on PTSD, depressive, and Obsessive-compulsive disorder (OCD) symptoms (specifically checking, ordering, washing, and obsessing symptoms), preoccupation with intrusive postpartum thoughts/neutralising strategies, and trauma exposure at 4 and 12 weeks postpartum. PTSD symptoms were strongly associated with all OCD symptoms (r = 0.32- 0.49, p < 0.001), preoccupation with postpartum-specific intrusive thoughts (r = 0.32-0.45, p < 0.001), and preoccupation with neutralising strategies (r = 0.21-0.29, p < 0.05) at both time points. PTSD symptoms were also predictive of checking and obsessing symptoms. This study identified PTSD symptoms as a new correlate for preoccupation with postpartum-specific intrusive thoughts and neutralising strategies in the postpartum period in a community sample. These findings add to the evidence suggesting a strong association between PTSD and OCD symptoms across the lifespan, including in non-clinical samples. Future research should examine best practices to assess and treat a variety of postpartum psychopathology symptoms, not just depression.

Changes in maternal psychological symptom profiles from 2 to 6 months postpartum: an application of latent transition analysis

To identify subgroups of postpartum women with different psychological symptom profiles at 2 and 6 months postpartum and to examine how they transition between symptom profiles over time using latent transition analysis (LTA). We used secondary data from the Family Life Project (N = 1,117) and performed LTA based on observed variables (depression, anxiety, somatization, and hostility). We examined transition probabilities and changes in latent status prevalence from 2 to 6 months postpartum. Considering the known influences of social determinants of health on psychological symptoms, bivariate analyses were conducted to describe the characteristics of different transition patterns. A 3-class model with better fit indices, entropy, and interpretability was selected. Based on symptom severity, the identified profiles were Profile 1: Low, Profile 2: Moderate, and Profile 3: High. From 2 to 6 months postpartum, the prevalence of low symptom profile decreased (82 to 78.2%) while the prevalence increased for moderate (15.8 to 17.5%) and high symptom profiles (2.2 to 4.4%). For all profiles, it was most likely for postpartum women to stay in the same profile from 2 to 6 months (low to low, moderate to moderate, and high to high). Those in persistent or worsening transition patterns were significantly younger or had less social support or education. Postpartum women in moderate or high symptom profiles at 2 months were most likely to stay in the same profile at 6 months postpartum, indicating persistent symptom burden. Clinicians should consider providing early, targeted support to prevent persistent symptom burden.

When is the best time to screen for perinatal anxiety? A longitudinal cohort study

BACKGROUND

For screening for anxiety during pregnancy and after birth to be efficient and effective it is important to know the optimal time to screen in order to identify women who might benefit from treatment.

AIMS

To determine the optimal time to screen for perinatal anxiety to identify women with anxiety disorders and those who want treatment. A secondary aim was to examine the stability and course of perinatal anxiety over time.

METHODS

Prospective longitudinal cohort study of 2243 women who completed five screening questionnaires of anxiety and mental health symptoms in early pregnancy (11 weeks), mid-pregnancy (23 weeks), late pregnancy (32 weeks) and postnatally (8 weeks). Anxiety and mental health questionnaires were the GAD7, GAD2, SAAS, CORE-10 and Whooley questions. To establish presence of anxiety disorders diagnostic interviews were conducted with a subsample of 403 participants.

RESULTS

Early pregnancy was the optimal time to screen for anxiety to identify women with anxiety disorders and women wanting treatment at any time during pregnancy or postnatally. These findings were consistent across all five questionnaires of anxiety and mental health. Receiving treatment for perinatal mental health problems was most strongly associated with late pregnancy and/or postnatal assessments. Anxiety symptoms were highest in early pregnancy and decreased over time.

CONCLUSION

Findings show that screening in early pregnancy is optimal for identifying women who have, or develop, anxiety disorders and who want treatment. This has clear implications for practice and policy for anxiety screening during the perinatal period.

"A Judgment-Free Zone": Adaptation and Pilot Study of a Virtual Wellness Group for African American Mothers with Young Children

The COVID-19 pandemic has been particularly challenging for the mental health of African American (AA) birthing people. The pandemic necessitated shifting mental health care to online interventions. The goals of this study were to (1) describe an adapted evidence-based group preventive intervention for AA mothers with young children within a pediatric setting and (2) evaluate the feasibility, acceptability, and preliminary effectiveness of this virtual intervention. Phase 1 describes the adaptation of the HealthySteps Mom's Virtual Wellness Group, including eight weekly sessions based on the Mothers and Babies Course. Phase 2 was a mixed-methods, pre-post intervention design. Six AA mothers with young children completed questionnaires related to depression, anxiety, and parenting competence at three time points: pre-intervention (T1), post-intervention (T2), and 3 months post-intervention (T3). The participants also completed a focus group post-T2 to gather qualitative feedback regarding the intervention. The median scores for depression were lower at T2 and increased at T3, and for anxiety, they increased at T2 and decreased at T3. The median scores for parenting competence increased across the three time points. The participants attended a mean of 7.2 sessions (SD = 0.74). The qualitative results indicate that the participants gained a sense of empowerment, enjoyed connecting with other mothers, and acquired information. This pilot study suggests that a virtual intervention is feasible, acceptable, and can increase parenting competence and support among AA mothers with young children.

Relevance of pharmacogenetic analyses and therapeutic drug monitoring of antidepressants for an individualized treatment of peripartum psychopathology

OBJECTIVE

Psychiatric disorders burden the peripartum period, often requiring psychopharmacological treatment, including antidepressants. Efficacy and tolerability of antidepressants are influenced by the physiological changes of the peripartum and individual metabolic profiles, which in turn can be modified by pregnancy. The objective of this study is to assess the relationship between antidepressants' pharmacokinetic profiles during pregnancy and individual metabolic profiles, along with the efficacy of the treatment.

METHODS

In total 87 outpatients with diagnoses of bipolar disorder, major depression, anxiety, obsessive-compulsive disorder and post-traumatic stress disorder who required antidepressant treatment during pregnancy were recruited. Genotyping analysis of hepatic cytochrome P450 (CYPs) individual isoforms was performed. Antidepressants' blood concentrations and psychometric assessments were collected at five time points. Antidepressants' cord blood concentrations were assessed at birth.

RESULTS

Sertraline showed greater stability in plasma concentrations and a lower placental penetrance index. Most of the antidepressants' concentrations below the therapeutic range were found in women with an extensive/ultrarapid metabolic profile. Antidepressants mainly metabolized by CYP2C19 were less frequently below the therapeutic range compared with antidepressants metabolized by CYP2D6.

CONCLUSIONS

Pregnancy modulates cytochrome activity and drugs' pharmacokinetics. Genotyping analysis of CYPs isoforms and therapeutic drug monitoring might be used to guide clinicians in a well-tolerated treatment of psychiatric symptoms in pregnant women.

The Pressing Need to Integrate Mental Health into Obstetric Care

Mental health and substance use conditions are prevalent among perinatal individuals. These conditions have a negative impact on the health of perinatal individuals, their infants, and families, yet are underdiagnosed and undertreated. Populations that have been marginalized disproportionately face barriers to accessing care. Integrating mental health into obstetric care could address the perinatal mental health crisis. We review perinatal mental health conditions and substance use, outline the impact associated with these conditions, and describe the promise and potential of integrating mental health into obstetric settings to improve outcomes for patients receiving obstetric and gynecologic care.

The Worry Behaviors Inventory-Perinatal Revised: Adaptation and Initial Validation for Use in Perinatal Samples

Generalized anxiety disorder (GAD) is a leading mental health concern during pregnancy and the postpartum (perinatal) period. People with GAD engage in problematic behaviors to manage their distress. However, the extent of GAD behaviors during the perinatal period may not be adequately captured by the Worry Behaviors Inventory (WBI), the most comprehensive measure of GAD behaviors to date. We evaluated the structure of the initial WBI item-pool and then evaluated the internal consistency, construct validity, and predictive utility of the Perinatal Revised WBI (WBI-PR) in a sample of 214 perinatal women with and without GAD. A two-factor, 10-item scale was supported, and some of the retained items differed from the original WBI. Internal consistency of the WBI-PR was acceptable, and evidence of construct validity was demonstrated. The WBI-PR predicted GAD diagnostic status both alone and beyond existing generalized anxiety and depression symptoms. Implications of these findings are discussed.

Mental health in the two years following hypertensive and normotensive pregnancy: The Postpartum, Physiology, Psychology and Paediatric follow-up (P4) cohort study

BACKGROUND

Postpartum mental illnesses and hypertensive disorders of pregnancy (HDP) are both common, and both associated with adverse maternal and child health outcomes. However, the relationship between them is unclear. This study aimed to investigate prevalence and symptom severity of depression, anxiety, and post-traumatic stress disorder (PTSD) 2-years postpartum in women with normal blood pressure (NBP) during pregnancy versus preeclampsia or gestational hypertension (GH).

METHODS

Two-years follow-up of the prospective Postpartum, Physiology, Psychology and Paediatric (P4) Cohort Study was conducted in metropolitan Australia. Prevalence and symptom severity of depression (Edinburgh Postnatal Depression Scale, EPDS > 12), anxiety (7-item Generalized Anxiety Disorder scale, GAD-7 ≥ 10) and PTSD (Posttraumatic stress Diagnostic Scale, PDS/PDS-5) were measured and calculated for women with NBP, preeclampsia and GH.

RESULTS

Among 365 participants (NBP: n = 271, preeclampsia: n = 75, GH: n = 19), 2-years postpartum depression prevalence was 3.9% (95% CI 2.3-6.4%): 4.4% after NBP, and 2.7% after preeclampsia (p = 0.53). Anxiety prevalence was higher after GH than NBP (15.8% versus 3.3%, p = 0.02). Prevalence of any mental illness (depression/anxiety/PTSD) was 5.9% (95% CI 3.8-8.8%); 5.6% after NBP, 4.1% after PE, and 15.8% after GH (p = 0.15). Although PTSD prevalence was low (1.4%), and similar between groups (p = 0.97), around 3 times more women after PE (8.1%), compared to NBP (2.5%), recalled childbirth as traumatic (p = 0.003).

CONCLUSIONS

Preeclampsia, although associated with persistent perceptions of traumatic childbirth, did not alter the risk of mental illnesses at 2-years postpartum. GH (albeit in a small subgroup) was associated with increased anxiety scores. Larger, multicentre studies are required to clarify relationships between HDP and postpartum mental illness.

TRIAL REGISTRATION

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry.

REGISTRATION NUMBER

ACTRN 12613 00,126 0718.

Screening, Assessment, and Treatment of Perinatal Mental Health in Obstetrical Settings

Perinatal mood and anxiety disorders (PMADs) are common, yet obstetricians receive little training prior to independent practice on screening, assessing, diagnosing, and treating patients with depression and anxiety. Untreated PMADs lead to adverse pregnancy and fetal outcomes. Obstetricians are in a unique position to address PMADs. The following serves as a resource for addressing PMADs in obstetric practice.

Perinatal anxiety disorders screening study: a study protocol

BACKGROUND

The anxiety and their related disorders (AD) are the most common of all mental health conditions, and affect approximately 20% of pregnant and postpartum people. They are associated with significant distress and life interference for sufferers, as well as negative consequences for fetal and infant development. At present, little if any routine screening for prenatal AD is being conducted and data regarding the most effective tools to screen for these disorders is lacking. The majority of screening studies suffer from methodological difficulties which undermine the confidence needed to recommend measures for population distribution. The primary purpose of this research is to identify the most accurate self-report tool(s) to screen for perinatal AD.

METHODS

A large, prospective cohort of pregnant people (N = 1,000) is being recruited proportionally across health service delivery regions in British Columbia (BC). The screening accuracy of a broad range of perinatal AD self-report measures are being assessed using gold standard methodology. Consenting individuals are administered online questionnaires followed by a semi-structured diagnostic interview between 16- and 36-weeks' gestation, and again between 6 and 20 weeks postpartum. Questionnaires include all screening measures, measures of sleep and unpaid family work, and questions pertaining to demographic and reproductive history, COVID-19, gender role burden, and mental health treatment utilization. Interviews assess all current anxiety disorders, as well as obsessive-compulsive disorder, and posttraumatic stress disorder.

DISCUSSION

This research is in response to an urgent demand for accurate perinatal AD screening tools based on high quality evidence. AD among perinatal people often go unidentified and untreated, resulting in continued suffering and life impairment. Findings from this research will inform healthcare providers, policymakers, and scientists, about the most effective approach to screening for anxiety and related disorders in pregnancy in the postpartum period.

What's next for the field of multigenerational mental health? The need for deep behavioral phenotyping via a prenatal mental health registry

From its inception, development and psychopathology theorists have sought to uncover the earliest forms of risk for mental health challenges in children, to prevent the development of more severe, intractable manifestations of psychopathology. Large familial risk registries have advanced our understanding of early, potentially modifiable factors that could prevent or mitigate the expression of challenging symptoms of neurodevelopmental conditions, and similar registries have been proposed to advance understanding of ADHD and related phenotypes. Data from single-site studies, largely focused on perinatal exposure to maternal mood disorders, reveal that a robust predictor of child psychopathology is parental psychopathology. However, early developmental trajectories of psychopathology risk may be better captured using transdiagnostic approaches in pregnancy, capturing the full range of mental health symptoms. We describe here the need for a parental mental health registry that begins prenatally that includes deep behavioral phenotyping across a range of transdiagnostic indicators of mental health risk to prevent psychopathology in children. This registry has the potential to uncover pathways to psychopathology risk in childhood and support the discovery of novel mechanisms to be targeted for prevention and intervention.

The role of perinatal maternal symptoms of depression, anxiety and pregnancy-specific anxiety for infant's self-regulation: A prospective longitudinal study

BACKGROUND

Maternal symptoms of anxiety and depression are highly prevalent during pregnancy and postpartum and have the potential to impact fetal development and offspring behavior. However, research on the effects of fetal exposure to maternal subclinical affective symptoms on infant self-regulation is still lacking. Self-regulation provides a fundamental precondition for healthy development and overall life success whereas dysfunctional self-regulation can lead to behavioral problems, poor academic achievement, social rejection, and physical/mental disorders. During pregnancy and infancy, children largely depend upon their mothers in order to successfully regulate their internal states. Given the high prevalence of mothers suffering from anxiety and depressive symptoms during pregnancy and after childbirth, the aim of the present study is to explore how maternal affective symptoms change during the pre- and postnatal period, and how measures obtained in pregnancy and beyond impact self-regulation in infants, as indicated by crying-, sleeping-, and/or feeding problems.

METHODS

This prospective longitudinal study investigates the effects of maternal symptoms of depression, anxiety, and pregnancy-specific anxiety on infant's self-regulation in N = 225 mother-infant dyads. Maternal affective symptoms were examined at five prenatal and three postnatal time-points using the Edinburgh Postnatal Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) and the Pregnancy Related Anxiety Questionnaire Revised (PRAQ-R2). Infant's self-regulation was assessed twice - at the age of three and six months - using the Crying Feeding Sleeping Scale (SFS).

RESULTS

Maternal pregnancy-specific anxiety was the most significant predictor for infant self-regulatory problems. It predicted crying-, sleeping, and feeding problems and explained up to 18 % of the variance. Even when controlling for maternal postpartum affective symptoms, pregnancy-specific anxiety remained a significant predictor for infant self-regulation problems.

LIMITATIONS

Rather homogenous sample (high socioeconomic status). Data based on maternal reports of infant behavior.

CONCLUSIONS

Our results suggest that fetal exposure to maternal affective symptoms - specifically pregnancy-related anxiety - plays a substantial role in the development of infant self-regulation problems, potentially mediated by epigenetic modifications. Importantly, even though maternal symptoms of depression and anxiety only reached subclinical levels, they were predictive for infant crying-, sleeping-, and feeding problems. Our findings underline the importance of early prevention and clearly tailored interventions during pregnancy and postpartum to prevent adverse outcome for mother, child and family.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

Regulatory T-cell phenotypes in prenatal psychological distress

BACKGROUND

Experiencing symptoms of psychological distress during pregnancy is common and has been linked to dysregulated immune functioning. In this context, immunoregulatory function is especially relevant because of its crucial role in establishment and maintenance of healthy pregnancy. However, little research has examined associations between women's prenatal psychological distress and immunoregulatory biomarkers. We investigated how symptoms of depression, anxiety, and stress relate to circulating levels of regulatory T-cells (Tregs).

MATERIALS AND METHODS

Pregnant Latina women were assessed at around 12 weeks of pregnancy (N = 82). These assessments included blood draws and self-report questionnaires assessing symptoms of depression, state anxiety, pregnancy-related anxiety, and perceived stress. Flow cytometry on PBMCs was used to quantify circulating Tregs, defined as CD3+CD4+CD25hiCD127loFoxP3+, and subpopulations positive for one of the following intra- or extracellular markers, CD45RA, CTLA-4, Helios, PD-1, TIM-3, and TIGIT. We collected 82 samples at 12 weeks. Multivariable linear regressions tested for associations between symptoms of psychological distress and Treg concentrations, adjusted for gestational age.

RESULTS

State anxiety symptoms at 12 weeks were negatively associated with parent Treg cell levels (b = -4.02, p = 0.023) and subpopulations Helios+ (b = -3.29, p = 0.019) and TIM3+ (b = -3.17, p = 0.008). Perceived stress was negatively associated with the PD-1+ subpopulation at 12 weeks (b = -4.02, p = 0.023). Depression was not related to Tregs or the subpopulations.

CONCLUSION

Our observation that symptoms of anxiety and stress are related to tolerogenic immunology suggests a possible biomechanism explaining correlations of maternal mood disorders with adverse outcomes for mothers and offspring.

Mental health outcomes beyond the post-partum period among adolescent mothers: a systematic review and meta-analysis

Background

Adolescence is the most crucial part of life. The vulnerability of adolescent mothers is even more pronounced and can affect various health aspects. While they suffer from social and emotional stresses shortly after giving birth, the long-term effect after the post-partum period of adolescent pregnancy on the mental outcomes holds prime importance. Thus, this systematic review aims to ascertain the association between adolescent pregnancy on mental health outcomes.

Methods

The search strategy was run in June 2023 on databases including PubMed, CINAHL, Scopus, Psych Info, and Embase . Quality assessment of the studies was done using the National Institute of Health (NIH)'s National Heart, Lung and Blood Institute (NHLBI) tool for observational studies. For studies that measured similar outcomes, a meta-analysis was conducted.

Findings

The search strategy yielded 21 results from all databases and cross-referencing. Of these, all except for one (case-control) were cross-sectional and cohort studies. The pooled analysis found a significant association between adolescent pregnancy and depression (RR 1.34; 95% CI 1.05, 1.72, 6 studies, heterogeneity: Chi2 P 0.01; I2 = 60%); however, no association was found in anxiety (RR 1.05; 95% CI 0.26, 4.14, 2 studies; heterogeneity: Chi² P = 0.0003; I2 = 93%) and suicidal ideation (RR 3.21; 95% CI 0.17, 59.33; 3 studies; heterogeneity: Chi2 P < 0.00001; I2 = 98%).

Implication

These findings suggest that the mental health needs of adolescent mothers must be addressed and innovative and effective interventions that support and address the mental health needs of adolescent mothers are needed to improve their mental health.

Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysis

BACKGROUND

Stress during pregnancy is detrimental to maternal health, pregnancy and birth outcomes and various preventive relaxation interventions have been developed. This systematic review and meta-analysis aimed to evaluate their effectiveness in terms of maternal mental health, pregnancy and birth outcomes.

METHOD

The protocol for this review is published on PROSPERO with registration number CRD42020187443. A systematic search of major databases was conducted. Primary outcomes were maternal mental health problems (stress, anxiety, depression), and pregnancy (gestational age, labour duration, delivery mode) and birth outcomes (birth weight, Apgar score, preterm birth). Randomized controlled trials or quasi-experimental studies were eligible. Meta-analyses using a random-effects model was conducted for outcomes with sufficient data. For other outcomes a narrative review was undertaken.

RESULT

We reviewed 32 studies comprising 3,979 pregnant women aged 18 to 40 years. Relaxation interventions included yoga, music, Benson relaxation, progressive muscle relaxation (PMR), deep breathing relaxation (BR), guided imagery, mindfulness and hypnosis. Intervention duration ranged from brief experiment (~10 minutes) to 6 months of daily relaxation. Meta-analyses showed relaxation therapy reduced maternal stress (-4.1 points; 95% Confidence Interval (CI): -7.4, -0.9; 9 trials; 1113 participants), anxiety (-5.04 points; 95% CI: -8.2, -1.9; 10 trials; 1965 participants) and depressive symptoms (-2.3 points; 95% CI: -3.4, -1.3; 7 trials; 733 participants). Relaxation has also increased offspring birth weight (80 g, 95% CI: 1, 157; 8 trials; 1239 participants), explained by PMR (165g, 95% CI: 100, 231; 4 trials; 587 participants) in sub-group analysis. In five trials evaluating maternal physiological responses, relaxation therapy optimized blood pressure, heart rate and respiratory rate. Four trials showed relaxation therapy reduced duration of labour. Apgar score only improved significantly in two of six trials. One of three trials showed a significant increase in birth length, and one of three trials showed a significant increase in gestational age. Two of six trials examining delivery mode showed significantly increased spontaneous vaginal delivery and decreased instrumental delivery or cesarean section following a relaxation intervention.

DISCUSSION

We found consistent evidence for beneficial effects of relaxation interventions in reducing maternal stress, improving mental health, and some evidence for improved maternal physiological outcomes. In addition, we found a positive effect of relaxation interventions on birth weight and inconsistent effects on other pregnancy or birth outcomes. High quality adequately powered trials are needed to examine impacts of relaxation interventions on newborns and offspring health outcomes.

CONCLUSION

In addition to benefits for mothers, relaxation interventions provided during pregnancy improved birth weight and hold some promise for improving newborn outcomes; therefore, this approach strongly merits further research.

Perinatal Mood and Anxiety Disorder and Reproductive Justice: Examining Unmet Needs for Mental Health and Social Services in a National Cohort

Introduction

Perinatal Mood and Anxiety Disorders (PMADs) are the most common complications during the perinatal period. There is limited understanding of the gaps between need and provision of comprehensive health services for childbearing people, especially among racialized populations.

Methods

The Giving Voice to Mothers Study (GVtM; n=2700), led by a multistakeholder, Steering Council, captured experiences of engaging with perinatal services, including access, respectful care, and health systems' responsiveness across the United States. A patient-designed survey included variables to assess relationships between race, care provider type (midwife or doctor), and needs for psychosocial health services. We calculated summary statistics and tested for significant differences across racialized groups, subsequently reporting odds ratios (ORs) for each group.

Results

Among all respondents, 11% (n=274) reported unmet needs for social and mental health services. Indigenous women were three times as likely to have unmet needs for treatment for depression (OR [95% confidence interval, CI]: 3.1 [1.5-6.5]) or mental health counseling (OR [95% CI]: 2.8 [1.5-5.4]), followed by Black women (OR [95% CI]: 1.8 [1.2-2.8] and 2.4 [1.7-3.4]). Odds of postpartum screening for PMAD were significantly lower for Latina women (OR [95% CI]=0.6 [0.4-0.8]). Those with midwife providers were significantly more likely to report screening for anxiety or depression (OR [95% CI]=1.81 [1.45-2.23]) than those with physician providers.

Discussion

We found significant unmet need for mental health screening and treatment in the United States. Our results confirm racial disparities in referrals to social services and highlight differences across provider types. We discuss barriers to the integration of assessments and interventions for PMAD into routine perinatal services.

Implications

We propose incentivizing reimbursement schema for screening and treatment programs; for community-based organizations that provide mental health and social services; and for culture-centered midwife-led perinatal and birth centers. Addressing these gaps is essential to reproductive justice.

Housing hardship and maternal mental health among renter households with young children

Maternal mental health is crucial to healthy family functioning and child well-being. Housing hardship may increase risk for mood disorders among mothers of young children in renter households. The present study used latent class analysis to investigate manifestations of housing hardship during the postpartum year in a sample of renter mothers in the United States (N = 2,329), as well as whether housing hardship types were associated with subsequent maternal depression and anxiety. The majority of mothers were relatively stably housed ("Stable"), one in six made do with governmental rental assistance ("Rent-Assisted"), and more than one in ten struggled to afford or maintain stable housing ("Cost-Burdened" or "Housing Insecure"). The most severe housing hardship was associated with the greatest depression risk, whereas the best determinant of anxiety risk was whether rent was paid each month; mothers whose rent was paid with government assistance did not differ on anxiety risk compared to those who paid their rent independently. Findings suggest that different types of housing hardship are linked with distinct mental health sequelae. Widely available housing assistance may reduce cost burden and prevent displacement, with the potential to reduce mental disorder among low-income mothers of young children.

Co-designing a nature-based intervention to promote postnatal mental health for mothers and their infants: a complex intervention development study in England

OBJECTIVES

There is burgeoning evidence for the potential of nature-based interventions to improve wellbeing. However, the role of nature in enhancing maternal mental health, child development and early relationships remains relatively unexplored. This study aimed to develop a co-designed nature-based intervention to improve postnatal mothers' and infants' wellbeing.

DESIGN, SETTING AND PARTICIPANTS

Person-based and co-design approaches informed the planning and design of the postnatal nature-based intervention. In stage 1, a multidisciplinary team was formed to agree research questions and appropriate methodology, and a scoping review was conducted. Six qualitative focus groups were then held with 30 mothers and 15 professional stakeholders. In stage 2, intervention guiding principles and a logic model were developed, and a stakeholder consensus meeting was convened to finalise the prototype intervention. The research was conducted in Bristol, UK, across voluntary, educational and community-based healthcare settings.

RESULTS

Stakeholder consultation indicated significant enthusiasm for a postnatal nature-based intervention. A scoping review identified little existing research in this area. Focus group data are reported according to four broad themes: (1) perceived benefits of a group postnatal nature-based intervention, (2) potential drawbacks and barriers to access, (3) supporting attendance and implementation, and (4) ideas for intervention content. The developed intervention was tailored for mothers experiencing, or at risk of, postnatal mental health difficulties. It was identified that the intervention should facilitate engagement with the natural world through the senses, while taking into account a broad range of postnatal-specific practical and psychological needs.

CONCLUSIONS

To our knowledge, this is the first reported use of person-based and co-design approaches to develop a postnatal nature-based intervention. The resulting intervention was perceived by target users to address their needs and preferences. Further research is needed to determine the feasibility, clinical and cost-effectiveness of this approach.

Nature-based interventions to support mental health and well-being of young women in pregnancy: exploratory work for future feasibility RCT

Background

The prevalence of mental health and well-being issues among young women is increasing. Pregnancy is a time when new mental health challenges may arise, or existing conditions can be exacerbated. This project presents preparatory work on how nature-based interventions may help to support the mental health and well-being of young pregnant women (aged 16-24 years) in a future study.

Methods

This project was formed of three main phases conducted from March to August 2022: (1) mapping nature activities available across the East Midlands region and two focus groups with providers of nature activities (n = 6); (2) public participation and involvement work to inform future research. This included four focus groups with young women (n = 11), leading to the formation of a new young women's panel (Research Influencers Group). Networking and stakeholder engagement to support future research.

Results

The mapping survey identified 68 nature-based organisations/projects operating in the region, many of whom expressed interest in being involved in future research. The young women's focus groups confirmed the importance of the topic and generated a wealth of information to support the intervention design. A Research Influencer Group of five young women was established from the focus group participants. The Research Influencer Group chose the nature-based intervention and had input into all aspects of the study design. This group will continue into future projects. Focus groups with providers of nature activities have further advanced the study design. The project team have developed relationships with relevant stakeholders and networks that will inform the future trial.

Conclusion

This preparatory co-design work suggested that a nature-based intervention may be acceptable to young women, and providers of such interventions felt it was feasible to offer these activities to young pregnant women. This preparatory work has led to an outline research plan which has been co-produced with public contributors and stakeholders throughout.

Limitations

This preparatory work is limited by small focus group samples, and the possibility that not all providers were reached through the snowballing approach to the mapping survey.

Future work

Future research is needed to test the nature-based intervention; this would be in the form of a feasibility randomised controlled trial of nature-based interventions to promote the mental health and well-being of young pregnant women.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR135167.

Mitochondrial might: powering the peripartum for risk and resilience

The peripartum period, characterized by dynamic hormonal shifts and physiological adaptations, has been recognized as a potentially vulnerable period for the development of mood disorders such as postpartum depression (PPD). Stress is a well-established risk factor for developing PPD and is known to modulate mitochondrial function. While primarily known for their role in energy production, mitochondria also influence processes such as stress regulation, steroid hormone synthesis, glucocorticoid response, GABA metabolism, and immune modulation - all of which are crucial for healthy pregnancy and relevant to PPD pathology. While mitochondrial function has been implicated in other psychiatric illnesses, its role in peripartum stress and mental health remains largely unexplored, especially in relation to the brain. In this review, we first provide an overview of mitochondrial involvement in processes implicated in peripartum mood disorders, underscoring their potential role in mediating pathology. We then discuss clinical and preclinical studies of mitochondria in the context of peripartum stress and mental health, emphasizing the need for better understanding of this relationship. Finally, we propose mitochondria as biological mediators of resilience to peripartum mood disorders.

Denis I, Zhu W, Mahaffey B, Lobel M. Anxiety trajectories from pregnancy to one-year postpartum and their contributors during the COVID-19 pandemic

BACKGROUND

Anxiety in the peripartum period (pregnancy through one-year postpartum) has negative impacts on mothers and infants. During the COVID-19 pandemic, high rates of anxiety were reported worldwide, but trajectories for how these symptoms change longitudinally in the peripartum period remain unknown.

METHODS

A total of 1,411 women who were pregnant during the second U.S. COVID-19 surge completed four study questionnaires between December 2020 and March 2022, including assessments of anxiety symptoms (GAD-7) and individual and community-level contributors. Latent Class Growth Mixture Models (LCGMM) were used to identify anxiety trajectories, and multinomial logistic regression was used to identify contributors to class membership.

RESULTS

Three classes of anxiety symptom trajectories were identified. Class 1 (n = 956, 67.8%) experienced minimal/mild anxiety throughout the peripartum period. Class 2 (n = 362, 25.7%) experienced initial moderate anxiety that remained stable. Class 3 (n = 93, 6.6%) experienced initial moderate anxiety that increased to severe in the postpartum period. Stress and history of mental health diagnosis contributed to higher initial levels of anxiety and ongoing social support contributed to lower levels of anxiety. In addition, financial insecurity increased the risk of belonging to Class 3.

CONCLUSIONS

Screening for anxiety symptoms and psychosocial vulnerabilities in the peripartum period is vital, as is early intervention. This is especially the case among women with limited financial and social resources who may experience chronic or worsening anxiety as they transition to parenthood.

Validation of the anxiety subscale of the Spanish version of the Edinburgh Postnatal Depression Scale (EPDS-A)

Introduction

There is a need to implement routine perinatal mental health screening in Spain. Therefore, it is necessary to systematise the detection of depressive and anxious symptoms in pregnancy and postpartum using the same instrument. The Edinburgh Postnatal Stress Depression Scale (EPDS) is frequently used as a rapid, effective and cross-culturally validated screening tool for perinatal depression. In several countries, an Anxiety subscale, the EPDS-A, was identified within the EPDS. Although the factorial structure of the EPDS has been investigated in Spanish population, the EPDS-A has not yet been validated. This study aimed to validate the EPDS-A as a measure of perinatal anxiety in Spanish population.

Methods

161 women were evaluated with the EPDS and the State-Trait Anxiety Inventory (STAI) during pregnancy and postpartum. Confirmatory factor analysis (CFA) was used to confirm the trifactorial structure of the EPDS, comprising the dimensions of Depression, Anhedonia and Anxiety. Likewise, the invariance of the trifactorial model between pregnancy and postpartum was tested. Finally, the correlations between the EPDS-A and the STAI subscales (State Anxiety and Trait Anxiety) were calculated.

Results

The Exploratory factor analysis (EFA) driven three-factor structure of the EPDS, consisting of an Anhedonia factor (Items 1, 2, and 10), an Anxiety factor (Items 3, 4, 5, and 6) and a Depression factor (Items 7, 8, and 9), was the best measurement model for the current data compared to the alternative model tested [χ2 = 34.592, df = 32, p = 0.34; χ2/df = 1.08; RMSEA = 0.023, 90% Confidence Interval [CI] [0.000, 0.064], CFI = 0.996, GFI = 0.960]. The model's invariance between pregnant and postpartum women was confirmed. The existence of an Anxiety subscale within the EPDS was also confirmed. The scores obtained with the EPDS-A correlated moderately with scores on both subscales of the STAI during pregnancy and after delivery. Using the STAI as a criterion and prioritising the instrument's sensitivity, a cut-off point of 4 points was established for the EPDS-A.

Conclusion

Our results confirm the trifactorial structure of the EPDS in Spanish population. The Anxiety subscale was validated for routine perinatal mental health screening.

How Exposure to Online Parenting Content Relates to Mothers' Self-Discrepancy and Postpartum Mental Health

Postpartum mental health problems are common and have deleterious effects on new mothers and their babies. This study developed a theoretically informed model of the relationship between exposure to images of motherhood in online parenting content and mothers' postpartum mental health. The model was tested using survey data collected from 509 Chinese mothers during their 12-month postpartum period. The results revealed that greater exposure to online public parenting content was indirectly related to lower levels of shame among new mothers via two mediators: the presumed influence of parenting media content on their partners, and the mothers' perceptions of the discrepancy between their actual selves as mothers and their partners' expectations of an ideal mother (i.e. actual/own - ideal/partner self-discrepancy). In contrast, increased exposure to online private parenting content shared by peers was indirectly related to increased levels of shame among new mothers via the mediation of social comparison with parenting media images, and of the mothers' perceptions of the discrepancy between their actual selves as mothers and their own expectations of an ideal mother (i.e. actual/own - ideal/own self-discrepancy). Additionally, new mothers were more likely to experience depressive symptoms and shame if they felt that they fell short of their partners' expectations of an ideal mother. However, increased social support reduced the anxiety and shame that stemmed from this belief.

Maternal anxiety, depression and posttraumatic stress disorder (PTSD) after natural disasters: a systematic review

OBJECTIVE

To measure the prevalence of maternal anxiety, depression and posttraumatic stress disorder (PTSD) in those exposed to natural disasters.

METHODS

A literature search of the PubMed database and www.clinicaltrials.gov from January 1990 through June 2020 was conducted. A PRISMA review of the available literature regarding the incidence and prevalence of maternal anxiety, depression and posttraumatic stress disorder (PTSD) following natural disasters was performed. A natural disaster was defined as one of the following: pandemic, hurricane, earthquake and post-political conflict/displacement of people. Studies were selected that were population-based, prospective or retrospective. Case reports and case series were not used. The primary outcome was the prevalence of maternal anxiety, depression and PTSD in the post-disaster setting. Two independent extractors (I.F. & H.G.) assessed study quality using an adapted version of the Effective Public Health Practice Project Quality Assessment tool. Given the small number of studies that met inclusion criteria, all 22 studies were included, regardless of rating. Data were extracted and aggregate rates of depression, anxiety, and PTSD were calculated to provide synthesized rates of maternal mental health conditions among participants.

RESULTS

Twenty-two studies met the inclusion criteria. A total of 8357 pregnant or birthing persons in the antepartum and postpartum periods were studied. The prevalence of post-pandemic anxiety, depression and PTSD were calculated to be 48.2%, 27.3%, and 22.9%. Post-earthquake depression and PTSD rates were 38.8% and 22.4%. The prevalence of post-hurricane anxiety, depression and PTSD were 17.4%, 22.5%, and 8.2%. The rates of post-political conflict anxiety, depression and PTSD were 48.8%, 31.6% and 18.5%.

CONCLUSION

Given the high rates of anxiety, depression and PTSD among pregnant and birthing persons living through the challenges of natural disasters, obstetrician-gynecologists must be able to recognize this group of patients, and provide a greater degree of psychosocial support.

Emotional and relational protective factors during pregnancy and psychological well-being and personal growth after childbirth

BACKGROUND

Studies in the perinatal literature tend to focus on potential negative outcomes, but little attention has been paid to the protective factors that may be associated with better psychological well-being or positive mental changes, such as personal growth.

OBJECTIVE

Drawing on the Broaden and Build Theory of Positive Emotions, the study employed a prospective design and a sequential mediation model to examine the mechanism by which protective factors during pregnancy (dispositional gratitude, perceived relationship quality with the partner, perceived maternal-foetal bonding) may be associated, in sequence, with higher psychological well-being and personal growth after childbirth among first-time mothers.

METHODS

The sample consisted of 515 women who were recruited through social media and completed questionnaires in two phases: Time 1, during the second half of their pregnancy; and Time 2, around 12 weeks after the birth of their first baby.

RESULTS

Results show that gratitude was associated with higher perceived relationship quality during pregnancy, which was associated with higher maternal-foetal bonding, which in turn was associated with higher psychological well-being and personal growth after childbirth. The indirect effects were significant.

CONCLUSION

The study expands knowledge of positive outcomes in the transition to motherhood, and demonstrates that positive emotions, such as gratitude, may be the first link in the chain of factors predicting better outcomes from pregnancy to childbirth.

Psychological distress in pregnancy and postpartum: a cross-sectional study of Babol pregnancy mental health registry

BACKGROUND

Psychological distress (PD) is a significant issue during pregnancy and postpartum, adversely affecting both children and mothers. This study aims to determine PD's prevalence and risk factors in a large Iranian population sample during pregnancy and postpartum.

METHODS

A cross-sectional study was conducted using data from the Babol Pregnancy Mental Health Registry (located in the north of Iran) between June 2020 and March 2021. A total of 2305 women were included, with 1639 during pregnancy and 666 during postpartum. Psychological distress was assessed using the Brief Symptoms Inventory (BSI-18), and data were analyzed using independent t-tests and multiple logistic regressions.

RESULTS

The prevalence of psychological distress, defined by a cut-off score of BSI ≥ 13, was 19% during pregnancy and 15% during postpartum. Multivariate logistic analysis revealed that high-risk pregnancy was the leading risk factor for psychological distress during the antenatal period (β = 1.776, P < 0.001), as well as its three subscales: somatization (β = 1.355, P = 0.019), anxiety symptoms (β = 2.249, P < 0.001), and depressive symptoms (β = 1.381, P = 0.028). Additionally, women with a gestational age < 20 weeks had a higher risk of psychological distress (β = 1.344, P = 0.038) and the somatization subscale (β = 1.641, P < 0.001). During the postpartum period, women residing in urban areas were at higher risk of psychological distress (β = 1.949, P = 0.012), as well as two subscales: anxiety symptoms (β = 1.998, P = 0.012) and depressive symptoms (β = 1.949, P = 0.020).

CONCLUSION

The high prevalence of psychological distress emphasizes detecting and treating PD during pregnancy and postpartum, particularly in women with high-risk pregnancies. This study suggests that obstetricians and midwives should implement programs to identify women experiencing psychological distress during early pregnancy through postpartum visits.