Effects of information-knowledge-attitude-practice health education combined with cluster-based care in patients with gestational hypertension

To analyze the impact of information-knowledge-attitude-practice (IKAP) health education incorporated with cluster-based care on blood pressure control, pregnancy outcome and life quality in those who have gestational hypertension, and to provide methodological backing for the care of patients. A total of 80 patients with pregnancy-induced hypertension were selected as the research objects and randomly divided into control and experimental groups, with 40 cases in each group. The control group received routine cluster care, which included providing individual and group health information through the distribution of health education manuals to hypertensive patients during pregnancy and their families. The experimental group received additional IKAP health education, including data collection, health knowledge imparted, concept change and behavior generation process. Blood pressure control status was measured and recorded. Adverse pregnancy outcomes include placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Postpartum quality of life conditions, including physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health were evaluated. Age, prepregnancy BMI, and educational level did not significantly vary between the 2 groups(P > .05). In comparison to the control group, the experimental group demonstrated healthier behavior. Blood pressure and weight control during pregnancy were better than control group. The frequency of adverse pregnancy was inferior to control group. The number of adverse neonatal conditions was inferior to control group. The postpartum quality of life score was higher in the experimental group compared to the control group. The combination of IKAP health education and cluster based care has a better effect on blood pressure control compared to the sole use of cluster based care. This approach can reduce the likelihood of experiencing adverse pregnancy outcomes and help improve the quality of life for patients after delivery.

Trial of a patient-directed eHealth program to ameliorate perinatal depression: the MomMoodBooster2 practical effectiveness study

BACKGROUND

Depression is one of the most common complications of childbirth, and is experienced by approximately 17% of pregnant women and 13% of postpartum women. An estimated 85% of these women go untreated-an alarming statistic given the serious consequences for the mother, her child, other family members, and society. Professional societies (the American College of Obstetricians and Gynecologists and American Academy of Pediatrics) have recommended improvements in screening and treatment. Meta-analyses indicate that cognitive behavioral therapy eHealth interventions are efficacious for depression, generally, and for perinatal depression, specifically. Earlier controlled trials have established the effectiveness and acceptability of MomMoodBooster (including an Australian version, MumMoodBooster), an eHealth program for ameliorating postpartum depression.

OBJECTIVE

This study aimed to evaluate the effectiveness of a perinatal version of MomMoodBooster encompassing both prenatal and postpartum content in a healthcare delivery setting already providing universal screening and referral of at-risk patients as part of routine care.

STUDY DESIGN

A practical effectiveness study randomly assigned 95 pregnant and 96 postpartum women screened as depressed and satisfying eligibility criteria to experimental groups: the healthcare organization's perinatal depression care program (routine-care group) and routine care+MomMoodBooster2 program (eHealth group). Eligibility criteria included: pregnant or <1 year postpartum, ≥18 years of age, no active suicidal ideation, access to broadband internet via desktop/laptop, tablet, or smartphone, and English language proficiency.

RESULTS

Intent-to-treat analyses of group effects used fixed-effects growth models to assess 12-week posttest change in outcomes. Results showed that both groups had significantly decreased depression severity, anxiety, stress, and automatic thoughts, and increased behavioral activation and self-efficacy. Relative to the routine-care group, the eHealth group displayed significantly greater decreases in depression severity and stress. These group comparisons were not moderated by depression severity (screening or baseline), anxiety, stress, or pregnant/postpartum status. Almost all (93%; n=89) women in the eHealth group visited their program, of whom 99% visited program sessions (M sessions visited=4.3±2.0; M total session duration=73.0±70.2 minutes; 49% viewed all 6 sessions). Among confirmed eHealth program users who provided ratings, 96% (79/82) rated their program as easy to use, 83% rated it helpful, and 93% (76/82) indicated that they would recommend it.

CONCLUSION

Results support the effectiveness of using MomMoodBooster2 as a treatment option for perinatal women with depression, especially when combined with universal depression screening and referral. Consequently, the eHealth program shows promise as a tool to increase the reach of treatment delivery and to potentially reduce the number of untreated perinatal women with depression.

Latent Trajectories and Risk Factors of Prenatal Stress, Anxiety, and Depression in Southwestern China-A Longitudinal Study

(1) Background: Few studies have explored the heterogeneity of trajectories of stress, anxiety, and depressive symptoms during pregnancy. This study aimed to explore the trajectory groups of stress, anxiety, and depressive symptoms in women during pregnancy and the risk factors associated with those groups. (2) Methods: Data came from pregnant women recruited from January to September 2018 in four hospitals in Chongqing Province, China. A structured questionnaire was given to pregnant women, which collected basic information, including personal, family, and social information. The growth mixture model was applied to identify potential trajectory groups, and multinomial logistic regression was applied to analyze factors of trajectory groups. (3) Results: We identified three stress trajectory groups, three anxiety trajectory groups, and four depression trajectory groups. Less developed regions, inadequate family care, and inadequate social support were associated with a high risk of stress; residence, use of potentially teratogenic drugs, owning pets, family care, and social support were strongly associated with the anxiety trajectory group; family care and social support were the most critical factors for the depression trajectory group. (4) Conclusions: The trajectories of prenatal stress, anxiety, and depressive symptoms are dynamic and heterogeneous. This study may provide some critical insights into the characteristics of women in the high-risk trajectory groups for early intervention to mitigate worsening symptoms.

The relationship between positive psychological qualities and prenatal negative emotion in pregnant women: A path analysis

Objective

The objective of this study was to investigate the relationship between positive psychological qualities and negative emotions of pregnant women.

Methods

We surveyed 774 pregnant women in a tertiary hospital in Urumqi using the following measures: a self-report general demographic data questionnaire, Generalized Anxiety Disorder scale (GAD-7), Patients Health Questionnaire depression scale (PHQ-9), Pregnancy Pressure Scale (stocktickerPPS), Perceived Social Support Scale (PSSS), General Self-Efficacy Scale (GSES), and Connor-Davidson Resilience scale (CD-RISC). We used the Amos2.03 system to build a structural equation model.

Results

A total of 774 subjects had an average age of 30 years and an average gestational age of 23 weeks. Among the 774 respondents, 122 (15.8%) had moderate or above pregnancy stress (stocktickerPPS > 1), 376 (48.6%) had mild or above anxiety symptoms (GAD-7 ≥ 5), 456 (58.9%) had mild or above depression symptoms (PHQ-9 ≥ 5), 740 (95.6%) had moderate or above social support scores (PSSS ≥ 37), and 124 (16.0%) had good or above psychological resilience scores (CD-RISC ≥ 60). Notably, 372 (48.1%) people had a self-efficacy score above the overall average (GSES ≥ 2.6). Pregnancy stress had positive correlations with anxiety and depression (β = 0.57, 0.30, P < 0.01) and negative correlations with self-efficacy (β = -0.19, P < 0.01). Anxiety had positive correlations with depression (β = 0.54, P < 0.01) and negative correlations with social support (β = -0.45, P < 0.01). Social support had positive correlations with self-efficacy and resilience (β = 0.37, 0.47, P < 0.01). Resilience had negative correlations with anxiety (β = -0.09, P < 0.01), and self-efficacy had positive correlations with resilience (β = 0.41, P < 0.01).

Conclusion

Identification of pregnancy stress should be emphasized in pregnant women with negative emotions. Efforts to strengthen the positive psychological qualities of pregnant women should focus on cultivating psychological resilience to reduce the occurrence of anxiety, and improving social support should be a priority because it can enhance psychological resilience and self-efficacy. We provide a reason to intervene in the negative emotions of pregnant women from the perspective of the positive psychology of pregnant women.

The mediating effect of resilience on pregnancy stress and prenatal anxiety in pregnant women

Objective

To investigate the relationship between pregnancy stress and prenatal anxiety in pregnant women in Urumqi, Xinjiang, and the mediating effect of mental resilience level on the relationship between pregnancy stress and prenatal anxiety.

Method

The investigation involved 750 pregnant women at a tertiary hospital in Urumqi, and included a questionnaire eliciting general demographic information, a pregnancy stress scale (Pregnancy Pressure Scale, PPS), generalized anxiety disorder scale (Generalized Anxiety Disorder-7, GAD-7), and a mental resilience scale (Connor-Davidson resilience scale, CD-RISC). The Bootstrap mediation effect test was used to test the effect relationship between variables, and Amos was used to establish the structural equation model.

Results

Among the 750 participants, 122 (16.2%) had moderate or greater pregnancy stress (PPS > 1), 372 (49.6%) had mild or greater anxiety symptoms (GAD-7 > 5), and 241 (32.1%) had good or higher mental resilience score. Pregnancy stress negatively affected resilience (β = -0.37, p < 0.01), and resilience also negatively affected prenatal anxiety (β = -0.12, p < 0.01). The mediating effect value of resilience was 8.3%.

Conclusion

Pregnancy stress, mental resilience, and prenatal anxiety were significantly correlated, and mental resilience played a partial mediating role in the influence of pregnancy stress on prenatal anxiety. It is recommended that pregnant women exercise their mental resilience to reduce the incidence of prenatal anxiety and promote physical and mental health.

Maternal prenatal infection and anxiety predict neurodevelopmental outcomes in middle childhood

Prenatal maternal infection and anxiety have been linked, in separate lines of study, with child neurodevelopment. We extend and integrate these lines of study in a large prospective longitudinal cohort study of child neurodevelopment. Data are based on the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort; prenatal maternal anxiety was assessed from self-report questionnaire; prenatal infection was derived from reports of several conditions in pregnancy (n = 7,042). Child neurodevelopment at approximately 8 years of age was assessed by in-person testing, reports of social and communication problems associated with autism, and psychiatric evaluation. Covariates included psychosocial, demographic, and perinatal/obstetric risks. Prenatal infection was associated with increased likelihood of co-occurring prenatal risk, including anxiety. Regression analyses indicated that both prenatal infection and prenatal anxiety predicted child social and communication problems; the predictions were largely independent of each other. Comparable effects were also found for the prediction of symptoms of attention problems and anxiety symptoms. These results provide the first evidence for the independent effects of prenatal infection and anxiety on a broad set of neurodevelopmental and behavioral and emotional symptoms in children, suggesting the involvement of multiple mechanisms in the prenatal programming of child neurodevelopment. The results further underscore the importance of promoting prenatal physical and mental health for child health outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effects of needs-based education for prenatal anxiety in advanced multiparas: a randomized controlled trial

Background

Prenatal anxiety is a common concern which may have adverse effects on maternal and infant health outcomes. Studies addressing needs-based education interventions for prenatal anxiety are limited.

Aim

To explore the effects of needs-based education on alleviating prenatal anxiety among advanced multiparas when compared with routine prenatal health education.

Methods

A total of 86 advanced multiparas were randomized into the intervention group (n = 43) or the control group (n = 43) in this study. The control group received routine prenatal care. The intervention group received five needs-based education programs presented by trained researchers. The Pregnancy-related Anxiety Questionnaire was used to evaluate changes in anxiety level of participants. Concurrent physiological parameters, including blood pressure, heart rate and non-stress test were also measured.

Results

Scores on the Pregnancy-related Anxiety Questionnaire of the intervention group were significantly lower than those of the control group (t = 4.21, P < 0.05). Systolic blood pressure (t = 3.64, P < 0.05) and heart rate (t = 2.39, P < 0.05) of the intervention group were also significantly lower than the control group whereas no differences were noted in diastolic blood pressure and non-stress test.

Conclusion

A needs-based education program is an effective intervention strategy to allay prenatal anxiety in advanced multiparas.

Trial registration

The trial was retrospectively registered in the Chinese Clinical Trial Registry as number ChiCTR2100047552.

Contributions of COVID-19 Pandemic-Related Stressors to Racial and Ethnic Disparities in Mental Health During Pregnancy

BACKGROUND

This study aimed to identify racial and ethnic disparities in prenatal mental health and identify COVID-19 pandemic-related health/healthcare and economic contributors to these disparities, using an established framework for disparity investigation.

METHODS

This cross-sectional study includes 10,930 pregnant people at Kaiser Permanente Northern California who completed an online survey between June 22, 2020 and April 28, 2021 on COVID-19 pandemic-related health/healthcare and economic stressors, depression, and anxiety. Self-reported race and ethnicity were extracted from electronic health records. Weighted analyses were used to evaluate the association between racial and ethnic category and prenatal depression and anxiety; the prevalence of each stressor by race and ethnicity; and the relationship between each stressor and prenatal depression and anxiety in each racial and ethnic category.

RESULTS

The sample was 22% Asian, 3% Black, 20% Hispanic, 5% Other/Multiracial/Unknown, and 49% White. Compared to White people, Black and Hispanic people had a higher prevalence of prenatal depression (aPR: 1.85, 95% CI: 1.45, 2.35 and aPR: 1.17, 95% CI: 1.00, 1.37, respectively) and anxiety (aPR: 1.71, 95% CI: 1.34, 2.18 and aPR: 1.10, 95% CI: 0.94, 1.29, respectively). Compared to White people, Black and Hispanic people had a higher prevalence of moderate/severe distress due to changes in prenatal care (24 vs. 34 and 31%), and food insecurity (9 vs. 31 and 24%). Among Black and Hispanic people, distress due to changes in prenatal care was associated with a greater prevalence of prenatal depression (aPR: 2.27, 95% CI: 1.41, 3.64 and aPR: 2.76, 95% CI: 2.12, 3.58, respectively) and prenatal anxiety (aPR: 3.00, 95% CI: 1.85, 4.84 and aPR: 2.82, 95% CI: 2.15, 3.71, respectively). Additionally, among Hispanic people, high-risk employment and food insecurity were associated with a greater prevalence of prenatal depression and anxiety.

CONCLUSIONS

This study identified racial and ethnic disparities in mental health for pregnant Black and Hispanic people. Distress due to prenatal care changes contributed to the observed disparities in prenatal depression and anxiety for Black and Hispanic people and food insecurity additionally contributed to the observed disparities for Hispanic people. Addressing distress due to changes to prenatal care and food insecurity specifically in Black and Hispanic people may help reduce the high burden of poor mental health and reduce observed disparities in these communities.

Systematic Review and Meta-Analysis

The prevalence of prenatal anxiety has increased during the COVID-19 pandemic. Anxiety is associated with other cardiovascular, physiological, and mental illnesses, resulting in adverse health effects for the mother and foetus. The purpose of this study was to evaluate the effects of physical activity (PA) during pregnancy on the prevalence of prenatal anxiety or symptoms of anxiety. A systematic review and two meta-analyses were performed (Registration No. CRD42021275333). Peer-reviewed articles reporting the effect of a PA intervention on anxiety during pregnancy were included. The first meta-analysis (MA) included 10 studies reporting final scores of prenatal anxiety. A negative association between moderate PA during pregnancy and prenatal anxiety was found in this analysis (z = −2.62, p < 0.01; ES = −0.46, 95% CI = −0.80, −12, I2 = 84%, Pheterogeneity = 0.001). The second MA included eight studies in which measures both before and after a PA intervention were reported. The findings of this analysis revealed a positive association between exercise practice during pregnancy and a decrease in prenatal anxiety scores (z = −3.39, p < 0.001; ES = −0.48, 95% CI = −0.76, −0.20, I2 = 71%, Pheterogeneity = 0.001). Supervised PA during pregnancy could prevent and reduce prenatal anxiety and anxiety symptoms.

Perinatal Mental Health; The Role and the Effect of the Partner: A Systematic Review

Pregnancy is a transitional period involving the most complex experiences in a woman's life, during which the woman's psychological status can be affected by a wide range of psychosocial variables. However, positive interpersonal relationships appear to constitute a supportive network that significantly influences perinatal mental health. Therefore, the presence of a supportive partner works psycho-protectively against the difficulties and pressures created by the transition to maternity. The aim of this study was to review systematically the influence of the partner on the woman's psychology during the perinatal period. Fourteen research articles from PubMed/Medline, Google Scholar and PsycINFO were included in the review from a total of 1846 articles. Most studies have shown a correlation between the support from the partner and prenatal depression and anxiety. Support from the spouse during childbirth is related to the extent to which women feel safe during labor as well as the stress during childbirth. The role of the partner is very important in the occurrence of perinatal mental disorders in women. Of course, more research needs to be done in the field of perinatal mental health. The risk factors that lead to mental disorders need to be clarified and the role of the partner in the perinatal period requires reinforcement and needs to be given the necessary importance.

Investigating prenatal perceived support as protective factor against adverse birth outcomes: a community cohort study

BACKGROUND

Studies show that prenatal maternal anxiety may act as a risk factor for adverse birth outcomes, whilst prenatal social support may rather act as a protective factor. However, studies examining prenatal anxiety symptoms, prenatal perceived support, and neonatal and/or obstetric outcomes are lacking.

OBJECTIVE

This study investigated whether, in a community sample, prenatal perceived support: (1) had a protective influence on birth outcomes (gestational age (GA), birthweight (BW), 5-minute Apgar score, and mode of delivery); (2) acted as a protective factor, moderating the relationship between anxiety symptoms and the aforementioned birth outcomes.

METHOD

During their third trimester of pregnancy, 182 nulliparous child-bearers completed standardized questionnaires of anxiety (HADS-A) and perceived support (MOS-SSS). Birth outcomes data was extracted from medical records.

RESULTS

(1) Perceived support did not significantly predict any birth outcomes. However, perceived tangible support - MOS-SSS subscale assessing perceived material/financial aid - significantly positively predicted the 5-minute Apgar score. (2) Perceived support did not significantly moderate the relationship between anxiety symptoms and birth outcomes. However, perceived tangible support significantly moderated the relationship between anxiety symptoms and the 5-minute Apgar score.

CONCLUSION

When experienced within non-clinical thresholds, prenatal anxiety symptoms do not increase the risk of adverse neonatal and obstetric outcomes when perceived support is present.

Associations between Physiological Biomarkers and Psychosocial Measures of Pregnancy-Specific Anxiety and Depression with Support Intervention

Stress and anxiety significantly impact the hypothalamic–pituitary axis, and in pregnancy, the subsequent maternal–fetal response can lead to poor outcomes. The objective of this study was to assess the association between psychosocial measures of pregnancy-specific anxiety and physiologic inflammatory responses. Specifically, to determine the effectiveness of the Mentors Offering Maternal Support (M-O-M-S^TM) program to reduce psychosocial anxiety and associated inflammatory response. In conjunction with measures of pregnancy-specific anxiety and depression, serum biomarkers (IL-2, IL-6, IL-10, IL1-B, TNF-α, CRH, CRP, and cortisol) were analyzed for each trimester throughout pregnancy. Results demonstrated that women receiving the M-O-M-S^TM intervention had longitudinally sustained lower TNF-α/IL-10 ratios than the control group, and it was significantly associated with psychosocial measures of anxiety, specifically for fears of labor and spouse/partner relationships. Additionally, the anxiety of spouse/partner relationships was significantly associated with IL-6/IL-10 ratios. The findings highlight the important counter-regulatory relationship between anti- and pro-inflammatory cytokines and provide insight into the distinct physiologic responses to pregnancy-specific anxiety with early prenatal intervention.

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

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

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

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

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

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

Perinatal emotional states: a comparative study between two cohorts recruited in a Mediterranean environment

Experiencing negative emotional states during pregnancy has been linked to adverse outcomes for mother and offspring. Our study aims were to compare the perinatal emotional states and obstetrical variables between pregnant women recruited in Spain (n = 202) and Italy (n = 103), and to investigate prenatal anxiety related factors. The study had two phases. In the 1^st phase (3^rd trimester of pregnancy), prenatal anxiety was assessed using the State-Trait Anxiety Inventory (STAI); other prenatal and sociodemographic variables were also collected. In the 2^nd phase (40 days postpartum), the STAI and the Edinburgh Postnatal Depression Scale were administered. Compared to the Spanish sample, the Italian sample presented higher STAI state and STAI factor 1 mean scores (22.5 vs. 18.6 and 10.0 vs. 7.2), shorter gestations (mean gestation weeks: 39.1 vs. 39.8), more unplanned pregnancies (31.1% vs. 16.4%), and more cesareans deliveries (42.5% vs. 16.0%). Low socioeconomic levels, younger ages, previous miscarriages and unplanned pregnancies were related to prenatal anxiety. Postpartum depression rates was 31.3% and there were no differences between countries. Our results suggested that it may be interesting in both countries to create a prenatal monitoring protocol that attaches more importance to emotional wellbeing both during pregnancy and in the long term.

The bloom is (slightly) off the rose: the motherhood effect on psychological functioning in successive pregnancies

Objective: To examine the maternal psychological state during the course of two successive pregnancies.Methods: The sample consisted of 73 women drawn from a larger maternal-fetal cohort that participated during two pregnancies. Women completed self-report psychological questionnaires at 24, 30, and 36 weeks gestation to index maternal depressive symptoms, trait anxiety, and pregnancy hassles and uplifts. Analyses examined stability of maternal symptoms across successive pregnancies in the same women.Results: Antenatal symptoms of depression and anxiety exhibited strong intra-individual stability between successive pregnancies. Mean differences in maternal symptoms were not detected for either at 24, 30, or 36 weeks gestation, excepting elevated anxiety symptoms at the mid-point due to greater fluctuation in maternal anxiety during the prior pregnancy. Subsequent pregnancies were associated with less intense uplifting feelings about the pregnancy on each measurement occasion.Conclusions: Findings suggest marked consistency in maternal psychological orientation across subsequent pregnancies, though parity also plays a role in the maternal experience.

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.

Development of a Psychological Intervention to Address Anxiety During Pregnancy in a Low-Income Country

Background: One in five women suffer from anxiety during pregnancy. Untreated anxiety is a risk factor for postnatal depression and is associated with adverse birth outcomes. Despite the high prevalence of prenatal anxiety in low- and middle-income countries (LMICs), efforts to develop and evaluate context-specific interventions in these settings are lacking. We aimed to develop a culturally appropriate, feasible, and acceptable psychological intervention for perinatal anxiety in the context of a low-income population in Pakistan. Methods: We conducted this research in Rawalpindi District at the Obstetrics Department of the Holy Family Hospital, Rawalpindi Medical University a government facility catering to a mixture of low-income urban, peri-urban, and rural populations. We used a mixture of research methods to: a) investigate the clinical, cultural, and health-service delivery context of perinatal anxiety; b) select an evidence-based approach that suited the population and health-delivery system; c) develop an intervention with extensive reference documentation/manuals; and d) examine issues involved in its implementation. Qualitative data were collected through in-depth interviews and focus group discussions, and analyzed using framework analysis. Results: Informed by the qualitative findings and review of existing evidence-based practices, we developed the "Happy Mother, Healthy Baby" intervention, which was based on principles of cognitive behavior therapy. Its evidence-based elements included: developing an empathetic relationship, challenging thoughts, behavior activation, problem solving, and involving family. These elements were applied using a three-step approach: 1) learning to identify unhealthy or unhelpful thinking and behavior; 2) learning to replace unhealthy or unhelpful thinking and behavior with helpful thinking and behavior; and 3) practicing thinking and acting healthy. Delivered by non-specialist providers, the intervention used culturally appropriate illustrations and examples of healthy activities to set tasks in collaboration with the women to encourage engagement in helpful behaviors. Feedback from the non-specialist providers indicated that the intervention was acceptable, feasible, and perceived to be helpful by the women receiving it. Conclusion: This new psychosocial intervention for perinatal anxiety, based on principles of cognitive behavior therapy and delivered by non-specialists, has the potential to address this important but neglected condition in LMICs.

Music Interventions for Anxiety in Pregnant Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Prenatal anxiety is extremely common and may result in adverse effects on both the mother and the baby. Music interventions have been used to reduce anxiety in various medical patients and in pregnant women during childbirth. This study aims to assess the clinical efficacy of music interventions in women during pregnancy rather than during labor. Seven databases were searched from inception to September 2019 without language restrictions. We included only randomized controlled trials that compared music intervention and control groups for anxiety reduction in pregnant women. We used the revised Cochrane risk-of-bias tool (RoB 2.0) for quality assessment. Finally, 11 studies with 1482 participants were included. The pooled meta-analysis results showed that music interventions significantly decreased anxiety levels (standardized mean difference (SMD), −0.42; 95% confidence interval (CI), −0.83 to −0.02; I² = 91%). Moreover, subgroup analysis showed that listening to music at home had significant anxiolytic benefits (SMD, −0.28; 95% CI, −0.47 to −0.08; I² = 0%). However, meta-regression revealed a nonsignificant trend for increase in the anxiety-reducing effects of music interventions with increasing maternal age. In conclusion, music interventions may be beneficial in reducing anxiety and may be applied in pregnant women.

Mediating Role of Labor on the Relationship Between Prenatal Psychopathologic Symptoms and Symptoms of Postpartum Depression in Women Who Give Birth Vaginally

OBJECTIVE

To investigate how prenatal symptoms of anxiety and depression and clinical aspects of labor (duration of labor, administration of oxytocin and epidural analgesia) interact with each other to contribute to symptoms of postpartum depression in women who give birth vaginally.

DESIGN

A longitudinal design with measurement at three different time points: Time 1, 31 to 32 weeks gestation; Time 2, the day of labor and birth; and Time 3, 1 month after birth.

SETTING

Maternity ward of the Misericordia e Dolce Hospital in Prato, Italy.

PARTICIPANTS

A total of 186 women at 31 to 32 weeks gestation were recruited during childbirth preparation courses at the maternity ward.

METHODS

At Time 1, women completed the Beck Depression Inventory and the State portion of the State-Trait Anxiety Inventory. At Time 2, midwives recorded clinical data related to labor, including duration of labor and administration of oxytocin and epidural analgesia. At Time 3, the women completed the Edinburgh Postnatal Depression Scale. Structural equation modeling was performed.

RESULTS

Symptoms of depression (β = 0.36; p < .001; 95% confidence interval [CI] [0.17, 0.49]) and state anxiety (β = 0.25; p < .001; 95% CI = [0.04, 0.27]) during pregnancy positively affected symptoms of depression after birth. Greater levels of these prenatal symptoms predicted a more complicated labor (depression: β = 0.29; p < .01; 95% CI [0.00, 0.19]; anxiety: β = 0.30; p < .01; 95% CI [0.01, 0.14]), which, in turn, positively predicted greater levels of symptoms of depression at 1 month after birth (β = 0.34; p < .001; 95% CI [0.38, 1.51]). Moreover, results highlighted indirect effects that high levels of anxiety symptoms during pregnancy have on postpartum symptoms of depression through the clinical aspects of labor (β = 0.10; p < .01; 95% CI [0.00, 0.13]). These indirect effects were not significant for antenatal symptoms of depression (β = 0.10; p < .05; 95% CI [-0.02, 0.20]).

CONCLUSION

Our findings confirm that symptoms of anxiety and depression during pregnancy represent significant risk factors for the clinical aspects of labor and for the development of symptoms of postpartum depression in the first month after childbirth.

Prospective evaluation of parental anxiety related to newborn foot disorder

PURPOSE

The presence of a clubfoot is often found prenatally and some families seek counselling with a specialist. The purpose of this study was to compare the parental anxiety levels in families that: a) knew prenatally and had prenatal counselling; b) knew prenatally but did not seek prenatal counselling; and c) did not know until after delivery.

METHODS

This prospective cohort study evaluated the anxiety of parents as they presented to the paediatric orthopaedic clinic with their newborn with a foot disorder (prior to the diagnostic confirmation of clubfoot). Each family filled out the 'Pre-visit orthopaedic surgeon questionnaire' and then after the initial visit with the orthopaedic surgeon (confirming the clubfoot diagnosis) the family filled out the 'Immediately post-visit orthopaedic surgeon questionnaire'. Through these questionnaires, anxiety level was assessed prior to meeting postnatally with the paediatric orthopaedic specialist, as well as after the meeting and compared across groups.

RESULTS

A total of 121 parents completed questionnaires: 71% (86/121) confirmed clubfoot; 69% of families (59/86) received prenatal counselling (Group A); 16% (14/86) knew prenatally but had no counselling (Group B); and 15% (13/86) found out at birth (Group C). There was no difference in anxiety levels across groups before (p = 0.78) or after (p = 0.57) meeting with the paediatric orthopaedic surgeon; however, overall anxiety reduced significantly (p < 0.001).

CONCLUSION

We found no difference in the anxiety levels of across the three groups. Prenatal counselling for parents of children with likely clubfoot may not decrease parental anxiety, but nonetheless is very appreciated by the families who receive it.

LEVEL OF EVIDENCE

Prognostic Level II.

Mentors Offering Maternal Support Reduces Prenatal, Pregnancy-Specific Anxiety in a Sample of Military Women

OBJECTIVE

To determine the efficacy of the Mentors Offering Maternal Support (MOMS) program to reduce pregnancy-specific anxiety and depression and build self-esteem and resilience in military women.

DESIGN

Randomized controlled trial with repeated measures.

SETTING

Large military community in Texas.

PARTICIPANTS

Pregnant women (N = 246) in a military sample defined as active duty or spouse of military personnel.

METHODS

Participants were randomized in the first trimester to the MOMS program or normal prenatal care. Participants attended eight 1-hour sessions every other week during the first, second, and third trimesters of pregnancy. Pregnancy-specific anxiety, depression, self-esteem, and resilience were measured in each trimester. Linear mixed models were used to compare the two-group difference in slope for prenatal anxiety, depression, self-esteem, and resilience.

RESULTS

The Prenatal Self-Evaluation Questionnaire was used to measure perinatal anxiety. Rates of prenatal anxiety on the Identification With a Motherhood Role (p = .049) scale and the Preparation for Labor (p = .017) scale were significantly reduced for participants in MOMS. Nulliparous participants showed significantly lower anxiety on the Acceptance of Pregnancy scale and significantly greater anxiety on the Preparation for Labor scale. Single participants had significantly greater anxiety on the Well-Being of Self and Baby in Labor scale, and participants with deployed husbands had significantly greater anxiety on the Identification With a Motherhood Role scale.

CONCLUSION

Participation in the MOMS program reduced pregnancy-specific prenatal anxiety for the dimensions of Identification With a Motherhood Role and Preparation for Labor. Both dimensions of anxiety were previously found to be significantly associated with preterm birth and low birth weight. Military leaders have recognized the urgent need to support military families.

Maternal perinatal mental health and offspring academic achievement at age 16: the mediating role of childhood executive function

BACKGROUND

Elucidating risk pathways for under-achieving at school can inform strategies to reduce the number of adolescents leaving school without passing grades in core subjects. Maternal depression can compromise the quality of parental care and is associated with multiple negative child outcomes. However, only a few small studies have investigated the association between perinatal maternal depression and poor academic achievement in adolescence. The pathways to explain the risks are also unclear.

METHOD

Prospective observational data from 5,801 parents and adolescents taking part in a large UK population cohort (Avon-Longitudinal-Study-of-Parents-and-Children) were used to test associations between maternal and paternal depression and anxiety in the perinatal period, executive function (EF) at age 8, and academic achievement at the end of compulsory school at age 16.

RESULTS

Adolescents of postnatally depressed mothers were 1.5 times (1.19, 1.94, p = .001) as likely as adolescents of nondepressed mothers to fail to achieve a 'pass' grade in math; antenatal anxiety was also an independent predictor of poor math. Disruption in different components of EF explained small but significant proportions of these associations: attentional control explained 16% (4%, 27%, p < .001) of the association with postnatal depression, and working memory explained 17% (13%, 30%, p = .003) of the association with antenatal anxiety. A similar pattern was seen for language grades, but associations were confounded by maternal education. There was no evidence that paternal factors were independently associated with impaired child EF or adolescent exams.

CONCLUSION

Maternal postnatal depression and antenatal anxiety are risk factors for adolescents underachieving in math. Preventing, identifying, and treating maternal mental health in the perinatal period could, therefore, potentially increase adolescents' academic achievement. Different aspects of EF partially mediated these associations. Further work is needed, but if these pathways are causal, improving EF could reduce underachievement in math.

Prenatal Anxiety and Infant Feeding Outcomes: A Systematic Review

Prenatal anxiety may negatively affect infant health in multiple domains, including infant feeding. However, the relationship between prenatal anxiety and infant feeding is not well understood. Given the benefits of recommended infant feeding practices, clarifying this relationship is important. This review was conducted to examine the relationship between prenatal anxiety and infant feeding outcomes. Electronic searches were performed in relevant databases. A hand search of selected journals and reference lists of included articles was then conducted. All studies were considered that provided information related to infant feeding outcomes and anxiety during pregnancy. Quality assessment and data extraction were conducted by 2 reviewers; 99 studies were identified, of which 6 were eligible. No associations were found between prenatal anxiety and breastfeeding initiation or breastfeeding in any quantity. However, relationships between high levels of prenatal anxiety and a reduction in both breastfeeding intention and breastfeeding exclusivity were identified. The review was limited by the small number of studies included. Sample sizes lacking power and heterogeneous measures and definitions all significantly affected the comparability of findings. It is concluded that there is insufficient evidence to clarify the relationship between prenatal anxiety and infant feeding outcomes.

Maternal Prenatal Mental Health and Placental 11β-HSD2 Gene Expression: Initial Findings from the Mercy Pregnancy and Emotional Wellbeing Study

High intrauterine cortisol exposure can inhibit fetal growth and have programming effects for the child's subsequent stress reactivity. Placental 11beta-hydroxysteroid dehydrogenase (11β-HSD2) limits the amount of maternal cortisol transferred to the fetus. However, the relationship between maternal psychopathology and 11β-HSD2 remains poorly defined. This study examined the effect of maternal depressive disorder, antidepressant use and symptoms of depression and anxiety in pregnancy on placental 11β-HSD2 gene (HSD11B2) expression. Drawing on data from the Mercy Pregnancy and Emotional Wellbeing Study, placental HSD11B2 expression was compared among 33 pregnant women, who were selected based on membership of three groups; depressed (untreated), taking antidepressants and controls. Furthermore, associations between placental HSD11B2 and scores on the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale (EPDS) during 12-18 and 28-34 weeks gestation were examined. Findings revealed negative correlations between HSD11B2 and both the EPDS and STAI (r = -0.11 to -0.28), with associations being particularly prominent during late gestation. Depressed and antidepressant exposed groups also displayed markedly lower placental HSD11B2 expression levels than controls. These findings suggest that maternal depression and anxiety may impact on fetal programming by down-regulating HSD11B2, and antidepressant treatment alone is unlikely to protect against this effect.

Maternal antenatal anxiety, postnatal stroking and emotional problems in children: outcomes predicted from pre- and postnatal programming hypotheses

BACKGROUND

Mothers' self-reported stroking of their infants over the first weeks of life modifies the association between prenatal depression and physiological and emotional reactivity at 7 months, consistent with animal studies of the effects of tactile stimulation. We now investigate whether the effects of maternal stroking persist to 2.5 years. Given animal and human evidence for sex differences in the effects of prenatal stress we compare associations in boys and girls.

METHOD

From a general population sample of 1233 first-time mothers recruited at 20 weeks gestation we drew a random sample of 316 for assessment at 32 weeks, stratified by reported inter-partner psychological abuse, a risk indicator for child development. Of these mothers, 243 reported at 5 and 9 weeks how often they stroked their infants, and completed the Child Behavior Checklist (CBCL) at 2.5 years post-delivery.

RESULTS

There was a significant interaction between prenatal anxiety and maternal stroking in the prediction of CBCL internalizing (p = 0.001) and anxious/depressed scores (p < 0.001). The effects were stronger in females than males, and the three-way interaction prenatal anxiety × maternal stroking × sex of infant was significant for internalizing symptoms (p = 0.003). The interactions arose from an association between prenatal anxiety and internalizing symptoms only in the presence of low maternal stroking.

CONCLUSIONS

The findings are consistent with stable epigenetic effects, many sex specific, reported in animal studies. While epigenetic mechanisms may be underlying the associations, it remains to be established whether stroking affects gene expression in humans.

Prenatal maternal anxiety predicts reduced adaptive immunity in infants

Prenatal anxiety has been linked with altered immune function in offspring in animal studies, but the relevance for human health is unknown. We examined prenatal maternal anxiety as a predictor of adaptive immunity in infants at 2 and 6 months of age as part of a prospective longitudinal study. The humoral immune response to hepatitis B vaccine was assessed at 2 months (n=80) and 6 months (n=76) of age. Prenatal anxiety predicted lower hepatitis B antibody titers at 6 months of age independent of obstetric and socio-demographic covariates; the effects were limited to those infants who had not completed the 3-dose vaccine series (for transformed titer values, r=-.36, p<.05). Cell-mediated immune responses at 2 (n=56) and 6 (n=54) months of age were examined by ELISpot assays for interferon(IFN)-γ, interleukin(IL)-2, and IL-4 responder cell frequencies to three antigens: hepatitis B surface antigen, tetanus toxoid, and phytohaemagglutinin (PHA). Prenatal maternal anxiety was associated with reduced IFN-γ and increased IL-4 responder cell frequencies at 6 months of age, independent of obstetric and socio-demographic covariates. No effect of prenatal anxiety was found on adaptive immunity at 2 months of age. The findings provide the first demonstration in humans that prenatal anxiety alters adaptive immunity in the infant.