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Pregnancy-related anxiety

 

Pregnancy is a significant transitional period in a woman’s life bringing about numerous physical, physiological, social, and psychological changes and demands. Consequently, a significant number of pregnant women report feelings of stress and anxiety. For instance, the prevalence of self-reported general anxiety symptoms ranges from 18.2% in early pregnancy to 24.6% in late pregnancy with a slight decrease after parturition. The prevalence of any anxiety disorder is ~15% during pregnancy, exceeding the prevalence of these disorders at other times in life. Further, more women report anxiety than depression during the perinatal period, while depression has received much more attention in the perinatal mental health literature, so far.



Pregnancy-related anxiety refers to anxieties specifically related to different aspects of pregnancy and, hence, is more situational or context-related than general anxiety, for example. It is typically conceptualized as an affective state consisting of any combination of concerns about one’s pregnancy, baby, self, hospital and health care, childbirth, and future parenting. For instance, a woman may be overly concerned about her own changing physical appearance or the health and wellbeing of the fetus. Also, excessive fear of childbirth is one manifestation of pregnancy-related anxiety. The symptoms are often preceded by real or anticipated threat to pregnancy or its outcomes, low perceived control, or excessive cognitive activity such as thinking of various uncertain scenarios, Symptom presentation usually span affective, cognitive, and somatic domains and is often associated with a range of negative behaviors and cognitive patterns, including negative attitudes, difficulty concentrating, rumination, and excessive reassurance-seeking.


Pregnancy-related anxiety is a partially separate concept from general anxiety, as generalized anxiety and depression seem to contribute only up to 15-20% of variance in pregnancy-related anxiety symptoms. Also, our recent still unpublished results from a large (N=3235) Finnish general population cohort of pregnant women (www.finnbrain.fi) show that only around 20% of women who report consistently elevated pregnancy-related anxiety symptoms throughout pregnancy score above a clinical threshold in depressive symptoms (i.e., the Edinburgh Postnatal Depression Scale, EPDS ≥12) in any pregnancy trimester. Hence, women suffering from significant anxiety symptoms during pregnancy may be poorly identified in the maternal healthcare systems.


Anxiety during pregnancy has been found to predict birth outcomes independently from medical risks and sociodemographic factors, and converging evidence shows similar patterns for pregnancy-related anxiety. For instance, preterm birth and low birth weight are more common among women reporting high stress and pregnancy-related anxiety. Since these are known to expose mothers and infants to significant medical and developmental risks, the screening and treatment of pregnancy-related anxiety should be seriously considered. Many studies also suggest that pregnancy-related anxiety may exert its effects on child development through prenatal programming, (i.e., developmental adaptations of the fetus in utero to maternal physiological signals of stress potentially resulting in structural, physiological, and metabolic changes), as the offspring of mothers with prenatal anxiety are at higher risk for motor, psychological, and neurodevelopmental adversities from infancy to adulthood. In conclusion, these symptoms may have a particularly significant impact on maternal adjustment, birth outcomes, and child development.


Since pregnancy-related anxiety is a rather new concept in the field, only few studies have examined interventions specifically for this symptom category. Image by Unsplash.
Since pregnancy-related anxiety is a rather new concept in the field, only few studies have examined interventions specifically for this symptom category. Image by Unsplash.

Pregnancy-related anxiety is not formally acknowledged in our diagnostic classifications (i.e., DSM V or ICD-11) while there may be some opportunities to use these systems e.g., by using a diagnosis for “generalized anxiety focused on pregnancy and parenthood” or “adjustment disorder”. However, these diagnoses naturally lack specificity and so the need for consideration of specifiers that are more specific and descriptive of pregnancy-related anxiety is obvious. Relatedly, the development of screening and/or diagnostic measures is still in process. Standardized instruments with at least some validity and reliability data exist for the screening of pregnancy-related anxiety. The Pregnancy-related Anxiety Questionnaire – Revised 2 (PRAQ-R2; Huizink et al., 2004, 2016) and the Stirling Antenatal Anxiety Scale (SAAS; Sinesi et al., 2020) both holds promise as brief screening tools for use in routine antenatal care or research. However, the scales do not provide validated cut-off scores that could be used to distinguish “positive” cases which is a current challenge for identification of the most severe cases of pregnancy-related anxiety. Further, to our knowledge pregnancy-related anxiety is not routinely screened in maternal healthcare systems in Nordic countries despite its potentially diverse negative effects on mother and the child. This would be an issue worth consideration as some interventions might be beneficial in alleviating pregnancy anxiety.


Since pregnancy-related anxiety is a rather new concept in the field, only few studies have examined interventions specifically for this symptom category. Based on systematic reviews psychological and psychosocial interventions are effective for non-specific anxiety in pregnancy, but few have considered pregnancy-related anxiety and further clinical trials are needed. First-line treatments for mild to moderate levels of pregnancy anxiety are usually psychological, and pharmacological treatment may be recommended for moderate to severe presentations of symptoms. Fear of childbirth, as one form of pregnancy-anxiety, is a treatable condition but also other aspects of anxiety and fear should be acknowledged and treated. In clinical practice, it is important to assess any co-occurring symptoms and risk factors to comprehensively evaluate the context of pregnancy-anxiety in a given individual. Therapies that use psychoeducation, with a target to pregnancy concerns and fears, or therapeutic techniques which aim to increase an expecting mother’s capacity to tolerate uncertainty and reduce suffering, and to calm the mind and body may be useful in providing effective short-term symptom relief and longer-term benefits. These include Cognitive Behavioral Therapy (CBT), Parent-Infant Psychotherapy, supportive counselling, and mindfulness-based therapies. However, only few Randomised Controlled Studies (RCTs) have been conducted, and further investigation is still warranted to create stronger conclusions of the most effective treatment of pregnancy-related anxiety. □

 

Further reading

  • Dryer, Rachel & Brunton, Robyn, Pregnancy-Related Anxiety – Theory, Research, and Practice, Routhledge, 2022.

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