The Prevalence of Pregnancy-Specific Perinatal Anxiety in Nova Scotia

Abstract

Objectives

Pregnancy-Specific Perinatal Anxiety (PSPA) is an understudied mental health condition of pregnancy that may affect maternal-fetal health outcomes. The purpose of this study was to determine the prevalence of PSPA among pregnant women in the province of Nova Scotia, Canada, as well as the factors associated with it.

Methods

A sample of 90 pregnant women provided data on PSPA symptomology and demographic co-variables via a self-report online survey. The prevalence of PSPA in the sample was calculated and bivariate statistics and binomial logistic regression were conducted to assess the relationship between the presence of PSPA and the independent variables.

Results

The prevalence of PSPA in our sample was 17.8%. Smoking during pregnancy and a pre-pregnancy diagnosis of anxiety were significantly associated with meeting the criteria for PSPA (p = 0.008 and p = 0.013, respectively) and strongly predicted the presence of PSPA (odds ratio 8.54 and 3.44, respectively).

Conclusions for Practice

A significant proportion of participants in our sample experienced symptoms consistent with a diagnosis of PSPA. This underscores the importance of further research on PSPA as a unique phenomenon in pregnant women, and the impact it may have on fetal and maternal health outcomes. A greater clinical emphasis should be placed on screening for and treating mental health conditions of pregnancy, including PSPA.

Significance

Anxiety in pregnancy affects maternal, fetal, and child health outcomes. A distinction – in terms of definition and diagnostic criteria – exists between generalized anxiety disorder (GAD) affecting pregnant women and pregnancy-specific perinatal anxiety (PSPA). The latter is a condition that has been identified as affecting pregnant women uniquely and with distinct clinical impact, but few studies have made effort to distinguish it from GAD when studying its prevalence and impact on health. This study examines the prevalence of PSPA exclusively and the variables associated with it to provide insight on the importance of this distinct clinical phenomena.

Introduction

Mental health illnesses are associated with negative adverse outcomes on maternal health during pregnancy, offspring health, and the mother-child relationship (Huizink et al., 2016). Although both depression and anxiety are common mental health illnesses that affect women of childbearing age (World Health Organization, 2021) and are associated with adverse maternal and fetal outcomes (Field, 2017), the pool of research that describes the prevalence and impact of perinatal depression largely outweighs the literature that exists on perinatal anxiety (Fawcett et al., 2019). More recent research has emerged pertaining to the prevalence and impact of perinatal anxiety, albeit with a dichotomy: generalized anxiety disorder (GAD) that occurs during pregnancy versus pregnancy-specific perinatal anxiety (PSPA) – a more distinct concept (Fawcett et al., 2019).

Perinatal anxiety, a relatively common phenomenon in pregnant women, is associated with significant adverse outcomes for pregnant women, neonates, and child physiology (Field, 2017). PSPA is distinct from general anxiety during pregnancy and affects infant and maternal factors independently (Blackmore et al., 2016). Mahrer et al., (2020) described PSPA as “… a context-specific form of anxiety rooted in fears and concerns regarding one’s current pregnancy. This type of anxiety may reflect concerns about one’s own health, health of the developing fetus, the impending childbirth, hospital and health-care experiences, and/or parenting ability. Pregnancy anxiety is empirically distinct from general anxiety and stress and has been shown to be a better predictor of adverse birth and developmental outcomes.”. Studying PSPA as a distinct concept is important to understanding its prevalence and potential impact on the health of pregnant and postpartum women and their children.

Despite the important results of these studies, a gap exists in the literature and in the current terminology. Many papers that discuss perinatal anxiety do not make the distinction between GAD and PSPA, which are separate clinical conditions (Fawcett et al., 2019). Those studies that do make the distinction often use measures that target anxiety in general, and do not capture PSPA uniquely (Anderson et al., 2019). In addition, several studies note the uniqueness of PSPA, but no term for the condition is used consistently across studies – making it difficult to compare results.

Research on the prevalence of PSPA has been heterogenous, and the existing measures of PSPA are also varied. Some measures address anxiety very generally, while others have a very narrow focus on pregnancy-related anxieties (Anja C. Huizink et al., 2004; Anderson et al., 2019). Anderson et al. (2019) compared pregnant patient scores of state anxiety, trait anxiety, and depression (through the Edinburgh Depression Scale, the State Trait Anxiety Inventory, and the International Personality Item Pool Neuroticism scale, respectively) to scores from surveys intended to measure PSPA specifically: the PRAQ-R2 (Pregnancy-Related Anxiety Questionnaire-Revised 2) and the Perinatal Anxiety Screening Scale (PASS). Their results showed that the PASS shared considerable variance with the measures of general anxiety and depression, while the PRAQ-R2 did not. This evidence supports the use of the PRAQ-R2 as a method to distinguish GAD from PSPA and appropriately quantify the prevalence of pregnant women displaying symptomology related to PSPA alone. Thus, we deemed the PRAQ-R2 to be the most appropriate to measure PSPA.

Prenatal screening currently centres around laboratory tests and diagnostic imaging, aiming to ensure a healthy pregnancy and normal development of the fetus. While these tests are considered important, evidence exists for the profound impact that anxiety and other mental health conditions can have on the health of the pregnant individual and developing baby (Mahrer et al., 2020). In Nova Scotia, a province in Eastern Canada, a standardized prenatal record prompts healthcare providers to take mental health into account at prenatal visits. However, the frequency with which this behaviour happens is, anecdotally, low.

Based on the impact of perinatal anxiety on health, the identification of PSPA as a condition unique to pregnant women with distinct clinical impact, and the gap in the current literature around this distinction and its prevalence, more research is needed. This study therefore aimed to explore the prevalence of PSPA, specifically in Nova Scotia,  and contribute to this budding area of perinatal research. To the best of the authors’ knowledge, this study was the first in Canada to specifically address the prevalence of PSPA.

Objectives

The primary objective of this study was to explore the prevalence of PSPA in a sample of pregnant women in Nova Scotia. The secondary objective was to identify correlates of PSPA in this sample.

Methods

Approval for this study was obtained from the IWK Research Ethics Board. All participation was in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants prior to participation.

This study was an observational, descriptive study with a single cross-sectional design. REDCap software (Harris et al., 2009, 2019) was used to create an online survey (see Appendix) that included questions from the Pregnancy-related Anxiety Questionnaire (PRAQ-R2), in addition to basic demographic information (Anja C. Huizink et al., 2004). An online consent form was embedded in the REDCap program that preceded the survey.

A convenience sample was recruited from a prenatal clinic in a tertiary hospital in Nova Scotia where family physicians and obstetricians provide prenatal care to women with low and high-risk pregnancies. Potential participants (pregnant women) were approached by one of the Care Team Assistants to determine their interest in completing the survey. Interested women were given a link or a QR code to a website (REDCap) containing the survey. Data were collected from July to September, 2020. Online data from the questionnaires were exported into SPSS Version 26 (IBM Corp., 2019).

The following variables were collected:

1. Dependent variable: Presence of PSPA (yes, no). This variable was measured with the PRAQ-R2, a 10-item questionnaire with statements related to PSPA on a Likert scale from 1 (absolutely not relevant) to 5 (very relevant). Total PRAQ-R2 score can range from 10 to 50, with higher scores indicating more symptoms in line with a diagnosis of PSPA and thus, a greater likelihood of having PSPA. The PRAQ-R2 has good psychometric properties and validity across cultures and gestational ages, however, it does not specify a cut off score above which PSPA should be diagnosed (Dellagiulia et al., 2020). To establish the presence or absence of PSPA for the current study, a cut-off point was needed. After personal correspondence with the original author of the PRAQ-R2 and examination of studies that have used the PRAQ-R2 as a measure for PSPA, a score of ≥ 34/50 was chosen as diagnostic of PSPA.

2. Independent variables: age (years), parity (0, ≥ 1), previous fetal loss(es) (yes, no), pre-pregnancy BMI (kg/m²), smoking prior to pregnancy (yes, no), smoking during pregnancy (yes, no), SES tercile (low, medium, high), pregnancy trimester (first, second, third trimester), pre-pregnancy diagnosis of anxiety disorder (yes, no), pregnancy classified as ‘high-risk’ (yes, no).

Data Analysis

Frequencies and means were used to describe the sample. Bivariate statistics were used to compare the presence of PSPA to the independent variables. Finally, binomial logistic regression of the independent variables on the dependent variable was undertaken.

Results

Ninety pregnant women consented to participate in this study. The mean age of participants was 32.1 years (SD = 4.6) and the mean pre-pregnancy BMI was 27.2 kg/m² (SD = 7.4). Most participants (48.3%) were nulliparous, 41.6% were primiparous, and 10.1% were multiparous. A few participants (4.5%) were in the first trimester, while 38.2% and 57.3% were in the second and third trimesters, respectively. While 25.6% of participants reported smoking prior to pregnancy, only 6.7% reported smoking during pregnancy. Most participants (77.5%) had never had a previous pregnancy loss, 68.9% had not been told that their current pregnancy was considered high risk, and 71.1% did not report a pre-pregnancy diagnosis of anxiety. Finally, 60.9% of participants were in the high SES tercile.

The PRAQ-R2 total scores were normally distributed. The mean score on the PRAQ-R2 was 27.3 (SD = 6.7, range 12.0–46.0). Sixteen participants scored ≥ 34 on the PRAQ-R2, indicating a prevalence of 17.8% (N = 16) for PSPA in our sample.

The characteristics of the sample, analyzed by presence or absence of PSPA, are shown in Table 1. Smoking during pregnancy (p = 0.008) and pre-pregnancy diagnosis of anxiety (p = 0.013) were significantly associated with PSPA. Odds ratios were calculated, and participants with a previous diagnosis of anxiety were 4.3 times more likely to have PSPA than participants without this diagnosis. Further, participants who smoked during pregnancy were 12 times more likely to have PSPA than participants who did not smoke during pregnancy. No relationships were identified between PSPA and age, pre-pregnancy BMI, parity, smoking prior to pregnancy, SES, having a high-risk pregnancy, having previous fetal losses, nor current pregnancy trimester.

Table 1.

Characteristics of the sample, by presence of PSPA

	PSPA absent (n=74)	PSPA present (n=16)	P value
Age, years (mean, SD)	32.2, 4.3	31.5, 5.7	0.63
Pre-pregnancy BMI, kg/m2 (mean, SD)	26.8, 7.2	28.9, 8.6	0.38
	n (%)	n (%)
Parity			0.27
0	33 (45.2)	10 (65.5)
≥ 1	40 (54.8)	6 (37.5)
Previous fetal loss			1.000
No	56 (76.7)	13 (81.3)
Yes	17 (23.3)	3 (18.8)
Smoking during index pregnancy			0.008
No	72 (97.3)	12 (75.0)
Yes	2 (2.7)	4 (25.0)
Smoking prior to index pregnancy			0.543
No	56 (75.7)	11 (68.8)
Yes	18 (24.3)	5 (31.3)
Current pregnancy trimester			0.881
First	3 (4.1)	1 (6.7)
Second	28 (37.8)	6 (40.0)
Third	43 (58.1)	8 (53.3)
Pre-pregnancy diagnosis of anxiety			0.013
No	57 (77.0)	7 (43.8)
Yes	17 (23.0)	9 (56.3)
High-risk pregnancy			1.000
No	51 (68.9)	11 (68.8)
Yes	23 (31.1)	5 (31.3)
SES tercile			1.000
Low	0 (0)	0 (0)
Medium	28 (38.8)	6 (40.0)
High	44 (61.1)	9 (60.0)

 

Discussion

Our results show that PSPA is an important diagnosis to consider during prenatal care visits. In our sample, 17.8% of women met the criteria for PSPA, indicating that almost one in five pregnant women experience high levels of anxiety that is specifically related to their pregnancy. This estimate is consistent with previous prevalence studies which reported prevalence rates ranging from 14.4% (Thorsness et al.,  2018) to 21–25% (Field, 2017), although different methods and definitions were used to calculate and quantify PSPA in those studies. The prevalence of PSPA identified in this study underlines the importance of placing greater value on screening for mental health conditions during prenatal visits and using appropriate scales to do so. Screening for PSPA should be undertaken, regardless of pre-pregnancy diagnosis of anxiety, to address women’s mental health concerns and improve health outcomes for women and babies. Education of prenatal care providers and distribution of appropriate scales for the measurement of PSPA would be beneficial.

Consistent with previous research (Leach et al., 2017), meeting the criteria for PSPA was significantly associated with both having a previous diagnosis of anxiety and smoking during pregnancy. As women with a pre-existing anxiety disorder could be expected to have high levels of anxiety in relation to their pregnancy as well, early identification and offer of support for these individuals could serve as a preventative measure to decrease their likelihood of developing PSPA. Further, it is plausible that individuals who smoke during pregnancy use smoking to cope with high levels of anxiety. As most people recognize that smoking is not healthy for the fetus, this behaviour may result in a cycle of guilt and anxiety about smoking, thus potentially explaining the increased incidence of PSPA in our participants who continued to smoke during pregnancy. This information is important when counselling pregnant smokers, where an emphatic approach should be employed to promote smoking cessation, while also being cognizant of reducing anxiety and guilt, and thus, decreasing level of PSPA.

We did not find a significant relationship between PSPA and other independent variables (age, parity, pre-pregnancy BMI, smoking before pregnancy, SES, having a high-risk pregnancy, having previous fetal losses, and pregnancy trimester). Some of these results are in contrast to previous research that report several risk factors for PSPA, including SES and psychosocial variables such as unintended pregnancy, low acculturation, low income, partner tension, younger maternal age, parity, and previous fetal loss (Field, 2017; Leach et al., 2017). These differences between our work and previous studies may be due to the high education and SES levels of our participants, rendering them not representative of the population of pregnant women, or because of the nonuniform terms, definitions, and scales used to measure PSPA in other studies.

We found that PSPA, a mental health condition unique to pregnant women, is fairly prevalent. Therefore, more research in this area and greater clinical emphasis on considering pregnancy-related mental health conditions should be considered. This study highlights the importance of prenatal screening for mental health conditions, in a manner that should be as routine as screening for pregnancy-related physical conditions (e.g., gestational diabetes).

Limitations

Our convenience sample was small, potentially limiting the limit the utility of the results, and did not include any participants in the low SES tercile. This latter characteristic is not representative of the population of pregnant women in Nova Scotia, and can be potentially attributed to the fact that our study required the use of a smart phone, thus excluding individuals without this technology. However, compared to the population of pregnant women in Nova Scotia, our sample had the same proportion of nulliparity (z = 0.802) and smoking during pregnancy (z = 1.914). The latter is important, as smoking during pregnancy was the greatest predictor for the presence of PSPA.

Strengths

Despite the study taking place during the covid-19 pandemic, prenatal care at the tertiary hospital’s prenatal clinic was carried out in person as usual. Patients were managed and triaged in the same fashion as before the pandemic, and thus the proportion of high-risk pregnant women being seen at this time was not increased. The patient demographics of the clinic were unaltered. As the first study of its kind in Canada, our findings have contributed important results to the budding area of research concerning pregnancy-specific mental health conditions. We anticipate that further research will be prompted to provide deeper insight into the national prevalence of PSPA, associated health outcomes, and preventative measures or treatment options.

Conclusion

Our results suggest that a substantial proportion of pregnant women in our province experience symptoms consistent with PSPA. This study adds to current literature that describes the prevalence of PSPA in pregnant women, demonstrating that mental health conditions are important variables to consider during prenatal visits and that specific scales are needed to target these conditions. The importance of further research on PSPA as a unique phenomenon in pregnant women, and the impact on fetal and maternal health outcomes that it has, is paramount. We hope that this study demonstrates the importance of screening for PSPA as a mental health condition in pregnant women, so that symptoms can be treated to improve health outcomes for mothers and babies.

Appendix

See Table 2.

Table 2.

Study survey with demographic questions followed by the PRAQ-R2

Demographic questions
	1. Age: ___
	2. Total number of pregnancies, including your current pregnancy: ___
	3. Total number of deliveries (births of children over 20 weeks of pregnancy, twins count as one delivery): ___
	4. Height: ___
	5. Weight, just before pregnancy: ___
	6. Before this pregnancy, did you smoke (cigarettes, vape, marijuana, etc.)? Yes/no
	7. During this pregnancy, do you smoke (cigarettes, vape, marijuana, etc.)? Yes/no
	8. First three digits of your postal code: ___
	9. Education: less than high school, graduated high school, some post-secondary, college degree, university degree, professional degree, advanced academic degree
	10. How many weeks pregnant are you now? ___
	11. Did you have a diagnosis of anxiety before this pregnancy? (Yes, no)

PRAQ-R2
Please circle each answer that applies most accurately to your situation: Absolutely not relevant, Hardly ever relevant, Sometimes relevant, Reasonably relevant, Very relevant
	1. I am anxious about the delivery.
	2. I am worried about the pain of contractions and the pain during delivery.
	3. I am worried about the fact that I shall not regain my figure after delivery.
	4. I sometimes think that our child will be in poor health or will be prone to illnesses.
	5. I am concerned about my unattractive appearance.
	6. I am worried about not being able to control myself during labour and fear that I will scream.
	7. I am worried about my enormous weight gain.
	8. I am afraid the baby will be mentally handicapped or will suffer from brain damage.
	9. I am afraid our baby will be stillborn, or will die during or immediately after delivery.
	10. I am afraid that our baby will suffer from a physical defect or worry that something will be physically wrong with the baby.

Author Contributions

Conceptualization: CL and HP; methodology: CL and HP; data analysis: HP and PA, writing: CL.

Funding

Dalhousie University Faculty of Medicine Gladys Osman Estate Studentship, awarded to CL.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Code Availability

Not applicable

Declarations

Conflict of interest

The authors declare that they have no relevant financial or non-financial interests to disclose.

Ethical Approval

Approval for this study was obtained from the IWK Research Ethics Board. All participation was in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to Participate

Informed consent was obtained from all individual participants prior to participation.

Consent for Publication

All participants consented to publication of their anonymous data prior to participation.