Abstract
INTRODUCTION
Postpartum anxiety affects approximately 1 in 4 women, with significant implications for both mothers and newborns. This study aimed to identify factors associated with postpartum anxiety and to assess its prevalence.
METHODS
A cross-sectional study was carried out with women in the postpartum period in Spain. To measure attachment (VAMF bonding and VAMF attachment), the Maternal-Child Bond and Attachment - VAMF tool was used. Purpose sampling method was used to collect data from postpartum and postnatal consultations in medical centers. Sociodemographic and obstetric variables, anxiety level (GAD-7), risk of intimate partner violence (WAST), and risk of postpartum depression (EPDS) were obtained. Odds ratios (ORs) and adjusted odds ratios (AORs) with their respective 95% confidence intervals (CIs) were calculated.
RESULTS
A total of 820 women participated, 36.1% (296) experienced mild anxiety, 8.5% (70) moderate anxiety, and 2.7% (22) severe anxiety. Key risk factors for anxiety included higher EPDS scores (adjusted odds ratio, AOR=1.68; 95% CI: 1.55–1.81), smoking (AOR=1.97; 95% CI: 1.01–3.82), a history of mental health issues (AOR=1.77; 95% CI: 1.13–2.79), and challenges related to the baby's health (AOR=2.70; 95% CI: 1.34–5.47). Additionally, a high-risk score on the WAST was linked to increased anxiety (AOR=1.53; 95% CI: 1.01–2.31). Conversely, protective factors included a positive mother–baby bonding score (AOR=0.90; 95% CI: 0.85–0.96) and a monthly income of 1000–1999 € (AOR=0.55; 95% CI: 0.31–0.95). For moderate to severe anxiety, a high EPDS score remained a notable risk factor (AOR=1.35; 95% CI: 1.26–1.44), while positive bonding (AOR=0.92; 95% CI: 0.85–0.98), higher income (>2000 €) (AOR=0.35; 95% CI: 0.15–0.80), and favorable treatment by healthcare providers significantly reduced anxiety risk (AOR=0.21; 95% CI: 0.07–0.70).
CONCLUSIONS
The prevalence of anxiety in women after childbirth is high. Depression, poor bonding, and economic status are factors that influence the onset of postpartum anxiety.
KEYWORDS: prevalence, associated factors, anxiety, postpartum
INTRODUCTION
When women become mothers, they are under tremendous pressure during the perinatal period, leading to anxiety and stress due to prevailing role models and social expectations1. The perinatal period is considered a critical phase in a woman’s life, and is not without difficulties for mental health2. In particular, the postpartum period can be emotionally challenging for mothers, with high levels of anxiety, stress, and depression.
Anxiety manifests itself through agitation, palpitations, nausea, control problems, irrational thoughts, or social avoidance3. Anxiety can begin to be experienced by a mother during pregnancy and up to the first year postpartum and is referred to as postpartum anxiety3.
Although postpartum anxiety is an underdiagnosed problem1, it can be present in up to 42% of women after giving birth4-6. This figure varies depending on severity and other factors, but globally, it is estimated that 1 in 4 women will experience postpartum anxiety, which can last up to a year after childbirth4.
Although the causes associated with the appearance of anxiety are varied, the literature has described socio-economic factors7, low social support8, obstetric variables such as the experience of childbirth and the type of birth, and even previous mental health disorders of the woman herself 9,10. Cohabitation with the partner and the couples’ relationship has also been described as a variable associated with the onset of postpartum anxiety11.
Anxiety, to whatever degree, has been associated with an increased likelihood of developing adverse outcomes in both mother and newborn12,13. Thus, in the postpartum period, anxiety can influence the attachment between the baby and the mother14. It can also affect the social and occupational level in the late postpartum period15.
Women who suffer from anxiety after childbirth may develop other disorders during the postpartum stage, such as postpartum depression7,12,16, maternal stress11 or suicidal ideation, which is the main predictor of perinatal suicide17,18. It has been estimated that anxiety-associated comorbidity costs an estimated £8.1 billion per birth cohort per year in countries such as the UK19.
Considering the magnitude and impact of postpartum anxiety on maternal and neonatal health, together with the few studies that address this pathology (most studies focus on postpartum depression), as well as the recommendation to carry out studies on postpartum anxiety20, the present study aims to study the factors associated with the presence of this postpartum anxiety, as well as to determine the prevalence of this disorder.
METHODS
Design and participant selection
A cross-sectional study was conducted on women who had given birth in Spain during the last half of 2021 and the first half of 2022 who met the following inclusion criteria: having given birth less than 18 months ago and not having suffered a neonatal loss. Women under 18 years of age and those who did not understand Spanish (language barrier) were excluded.
In an attempt to estimate the sample size to obtain valid estimations, the maximum modeling principle21 was followed. This requires 10 events (women with anxiety) per each included variable. Considering that the prevalence in this reference population and sociodemographic context ranges 20–25%5, it would be necessary to recruit a sample of 800 women (200 with anxiety) for an initial model of 20 variables.
The questionnaire was distributed by collaborating health workers in the clinical setting, including during postpartum and postnatal consultations, as well as midwifery consultations in medical centers (including hospital or health center as well as midwife-led clinics). This allowed more women to be recruited (via purpose sampling method) including during the subsequent check-ups where the mother attended with the newborn. Once women were selected, they were given the information about the study and lately the choice to participate and sign the informed consent form. Mechanisms for resolving queries were established through a WhatsApp group among collaborating professionals in order to provide homogeneous answers to any questions that might arise.
Ethical considerations
The present study was approved by the Research Ethics Committee of the Province of Jaén (DCVA-21/2012-N-21). All women participating in the study signed the informed consent form.
Information source and study variables
The data were collected using a self-developed, previously piloted questionnaire, which was distributed in different hospitals and health centers. This questionnaire contained open and closed questions, with a language understandable to all educational levels. It included sociodemographic variables such as age, income level, lifestyles such as alcohol or tobacco consumption, obstetric, family, and personal history of the pregnancy itself, and also variables related to the newborn. To assess the presence of anxiety, the Generalized Anxiety Disorder Screener (GAD-7) scale was used in its validated version in a population similar to that of our study20. The GAD-7 is a self-administered 7-item scale with four response options in ascending order from 0 to 4 points (never, several days, half of the days, almost every day), with a score ≥5 indicating the presence of anxiety and ≥10 indicating moderate or severe anxiety20.
To measure mother-child bond and attachment, the "Maternal - Child Bond and Attachment" ("VAMF", for its initials in Spanish) tool was used. The VAMF tool is a self-administered 29-item scale that measures mother-child bonding and attachment, and is designed and validated for application in the postpartum period and up to 18 months of age of the infant. The Edinburgh Postpartum Depression Scale (EPDS)23 was used to determine the risk of postpartum depression (PPD). The Woman Abuse Screening Tool (WAST) was used to screen for Intimate Partner Violence (IVP)24. All these instruments have been validated in a population similar to that of the present study.
Statistical analysis
For sociodemographic and clinical data, absolute (n) and relative frequencies (%) were used to describe qualitative variables, and mean and standard deviation (SD) were used to describe quantitative variables. A bivariate and multivariate analysis was then performed between anxiety risk and moderate-severe anxiety risk with possible associated factors. In the first case, anxiety risk was considered as ‘No anxiety’ with scores <5 on the GAD-7 and ‘Anxiety’ with scores ≥5. In the case of moderate-severe anxiety risk, the comparison was between ‘Low or no anxiety levels’ with scores <10 and ‘Moderate-severe anxiety’ with scores ≥10.
Binary logistic regression was used to estimate odds ratios (ORs) and adjusted odds ratios (AORs) with their respective 95% confidence intervals. When multivariate analysis was performed, the backward stepwise procedure was used, and all variables from the bivariate analysis were included whether or not statistical significance was observed. For this analysis, the dependent variable GAD-7 score was dichotomized, while the independent variables were entered into the model in their original form (age, the VAMF and EPDS scales continuously and without transformations or categorizations).
Finally, the predictive ability of the model was estimated using the area under the receiver operating characteristic (ROC) curve (AUC). In order to assess the prediction in qualitative terms, the Swets criterion25 was used with values: 0.5–0.6 (bad), 0.6–0.7 (poor), 0.7–0.8 (satisfactory), 0.8–0.9 (good), and 0.9–1.0 (excellent). The statistical program SPSS 29.0 was used for data analysis.
RESULTS
A cross-sectional study was conducted with 820 postpartum women in Spain. The mean age was 34.30 years (SD=4.06), 58.7% (481) were primiparous and 41.2% (338) were multiparous; 9.0% (47) of the women had an unplanned pregnancy, while 13.5% (111) needed fertility treatment. A total of 24.9% (204) had experienced some mental issues during their lifetime. In terms of experience during labor, 11.5% (94) had a bad experience, and 70.4% (577) defined it as good or very good. The treatment received by the professional healthcare team was defined as bad or very bad by 3.4% (28) women, while 88.9% (729) described it as good or very good; 33.8% (277) of the women were screened as high-risk from suffering IPV. The mean score of EPDS was 7.44 (SD=4.70). Related to anxiety, 52.7% (423) of the women did not suffer any kind of anxiety, whereas 36.1% (296) suffered from mild anxiety, 8.5% (70) moderate, and 2.7% (22) severe anxiety. The mean score of anxiety in the whole sample was 4.94 (SD=3.83). The rest of the data can be seen in Table 1.
Table 1.
Sociodemographic and clinical characteristics of the study sample, Spain, 2021–2022 (N=820)
| Variable | Mean (SD) |
|---|---|
| Age (years) | 34.30 (4.06) |
| EPDS | 7.44 (4.70) |
| VAMF bonding | 57.81 (3.91) |
| VAMF attachment | 42.72 (4.87) |
| GAD-7 | 4.94 (3.83) |
| Variable | n (%) |
| Anxiety level | |
| No anxiety | 432 (52.7) |
| Mild | 296 (36.1) |
| Moderate | 70 (8.5) |
| Severe | 22 (2.7) |
| Income level (€) | |
| <1000 | 140 (17.1) |
| 1000–1999 | 444 (54.1) |
| >2000 | 236 (28.8) |
| Alcohol consumption | |
| Never | 272 (33.2) |
| Occasionally | 492 (60.0) |
| Frequently | 56 (6.8) |
| Smoking habit | |
| No | 740 (90.2) |
| Yes | 80 (9.8) |
| Number of children | |
| 1 | 599 (73.0) |
| 2 | 191 (23.3) |
| ≥3 | 30 (3.7) |
| Pregnancy | |
| 1 | 481 (58.7) |
| 2 | 222 (27.1) |
| ≥3 | 116 (14.1) |
| Missing | 1 (0.1) |
| Planned pregnancy | |
| No | 74 (9.0) |
| Yes | 746 (91.0) |
| Cesarean birth | |
| No | 608 (74.1) |
| Yes | 212 (25.9) |
| Fertility treatment (IVF, egg donation, etc.) | |
| No | 709 (86.5) |
| Yes | 111 (13.5) |
| Depression (current) | |
| No | 741 (90.4) |
| Yes | 79 (9.6) |
| Antenatal classes | |
| No | 217 (26.5) |
| Yes | 603 (73.5) |
| High risk pregnancy | |
| No | 695 (84.8) |
| Yes | 125 (15.2) |
| Any illness (current) | |
| No | 721 (87.9) |
| Yes | 99 (12.1) |
| Mental health issues (any time during life) | |
| No | 616 (75.1) |
| Yes | 204 (24.9) |
| Feeling tired during pregnancy, labor or postpartum | |
| No | 85 (10.4) |
| Yes | 735 (89.6) |
| Type of birth | |
| Vaginal | 484 (59.0) |
| Instrumental | 158 (19.3) |
| Cesarean section (elective) | 45 (5.5) |
| Cesarean section (emergency) | 133 (16.2) |
| Admission to ICU | |
| No | 809 (98.7) |
| Yes | 11 (1.3) |
| Hospital readmission | |
| No | 802 (97.8) |
| Yes | 18 (2.2) |
| Baby admission to pediatrics unit | |
| No | 734 (89.5) |
| Yes | 67 (8.2) |
| Yes, NICU admission | 19 (2.3) |
| Skin-to-Skin | |
| No | 123 (15.0) |
| Yes | 697 (85.0) |
| Preterm baby | |
| No | 782 (95.4) |
| Yes | 38 (4.6) |
| Baby with problem (current) | |
| No | 740 (90.2) |
| Yes | 80 (9.8) |
| Currently breastfeeding | |
| No | 98 (12.0) |
| Yes | 722 (88.0) |
| Experience during labor | |
| Bad or very bad | 94 (11.5) |
| Not sure | 149 (18.2) |
| Good or very good | 577 (70.4) |
| Experience (professional treatment) | |
| Bad or very bad | 28 (3.4) |
| Not sure | 63 (7.7) |
| Good or very good | 729 (88.9) |
| Support received from family | |
| Low or very low | 69 (8.4) |
| Moderate | 160 (19.5) |
| High or very high | 591 (72.1) |
| WAST (IPV Risk) | |
| Low risk | 543 (66.2) |
| High risk | 277 (33.8) |
The relation between the different scales was studied, finding a statistically significant relation between the mean score of EPDS (p≤0.001), VAMF bonding (p≤0.001), and VAMF attachment (p=0.002), and the presence of any kind of anxiety. This can be seen in Table 2.
Table 2.
Distribution of scores between EPDS, VAMF bonding, VAMF attachment, and the presence of anxiety, Spain, 2021–2022 (N=820)
| Variable | Anxiety | |||
|---|---|---|---|---|
|
No
mean(SD) (N=432) |
Yes
mean (SD) (N=388) |
Mean difference
(95% CI) |
p | |
| Age (years) | 34.37 (4.28) | 34.21 (3.79) | 0.16 (-3.98–0.72) | 0.079 |
| EPDS | 4.61 (2.81) | 10.59 (4.35) | -5.98 (-6.48 – -5.49) | ≤0.001 |
| VAMF bonding | 59.01 (2.89) | 56.47 (4.44) | 2.54 (2.03–3.04) | ≤0.001 |
| VAMF attachment | 43.06 (4.48) | 42.34 (5.25) | 0.72 (0.05–1.39) | 0.002 |
Subsequently, bivariate and multivariate analyses were performed to determine which factors were associated with any kind of anxiety on the GAD-7 questionnaire compared to no anxiety. Factors that were associated with a higher GAD-7 score were a high EPDS score (AOR=1.68; 95% CI: 1.55–1.81), smoking habit (AOR=1.97; 95% CI: 1.01–3.82), had suffered from any mental issues during lifetime (AOR=1.77; 95% CI: 1.13–2.79), baby having any problem currently (AOR=2.70; 95% CI: 1.34–5.47), or WAST screen positive as high-risk (AOR=1.53; 95% CI: 1.01–2.31). Protective factors associated with anxiety included the VAMF bonding score (AOR=0.90; 95% CI: 0.85–0.96) and a monthly income level between 1000–1999 € (AOR=0.55; 95% CI: 0.31–0.95) appeared. This can be seen in Table 3. The predictive capability for anxiety risk presented a AUC-ROC of 0.90 (95% CI: 0.88– 0.92), with an exceptional capability to classify subjects according to the Swets criterion. The ROC curve can be seen in Figure 1.
Table 3.
Bivariable and multivariate analysis of the factors associated with anxiety compared to no anxiety, on the GAD-7 questionnaire, Spain, 2021–2022 (N=820)
| Anxiety | ||||
|---|---|---|---|---|
|
No
(GAD-7 <5) |
Yes
(GAD-7 ≥5) |
OR (95% CI) | AOR (95% CI) | |
| Variable | Mean (SD) | Mean (SD) | ||
| Age (years) | 34.37 (4.28) | 34.2 (3.79) | 0.99 (0.96–1.02) | |
| EPDS | 4.61 (2.81) | 10.59 (4.35) | 1.69 (1.57–1.81) | 1.68 (1.55–1.81) |
| VAMF bonding | 59.01 (2.89) | 56.47 (4.44) | 0.82 (0.79–0.86) | 0.90 (0.85–0.96) |
| VAMF attachment | 43.06 (4.48) | 42.34 (5.25) | 0.97 (0.94–0.99) | |
| Variable | n (%) | n (%) | ||
| Income level (€) | ||||
| <1000 ® | 62 (44.3) | 78 (55.7) | 1 | 1 |
| 1000–1999 | 235 (52.9) | 209 (47.1) | 0.71 (0.48–1.04) | 0.55 (0.31–0.95) |
| >2000 | 135 (57.2) | 101 (42.8) | 0.60 (0.39–0.91) | 0.54 (0.29–0.99) |
| Alcohol consumption | ||||
| Never ® | 141 (51.8) | 131 (48.2) | 1 | |
| Occasionally | 260 (52.8) | 232 (47.2) | 0.96 (0.71–1.29) | |
| Frequently | 31 (55.4) | 25 (44.6) | 0.87 (0.49–1.55) | |
| Smoking habit | ||||
| No ® | 395 (53.4) | 345 (46.6) | 1 | 1 |
| Yes | 37 (46.3) | 43 (53.8) | 1.33 (0.84–2.11) | 1.97 (1.01–3.82) |
| Number of children | ||||
| 1 ® | 324 (54.1) | 275 (45.9) | 1 | |
| 2 | 90 (47.1) | 101 (52.9) | 1.32 (0.95–1.83) | |
| ≥3 | 18 (60.0) | 12 (40.0) | 0.79 (0.37–1.66) | |
| Pregnancies | ||||
| 1 ® | 253 (52.6) | 228 (47.4) | 1 | |
| 2 | 118 (53.2) | 104 (46.8) | 0.98 (0.71–1.35) | |
| ≥3 | 61 (52.6) | 55 (47.4) | 1.00 (0.67–1.50) | |
| Planned pregnancy | ||||
| No ® | 25 (33.8) | 49 (66.2) | 1 | 1 |
| Yes | 407 (54.6) | 339 (45.4) | 0.43 (0.26–0.70) | 0.54 (0.26–1.09) |
| Cesarean birth (previous) | ||||
| No ® | 332 (54.6) | 276 (45.4) | 1 | |
| Yes | 100 (47.2) | 112 (52.8) | 1.35 (0.99–1.84) | |
| Fertility treatment (IVF, egg donation, etc.) | ||||
| No ® | 372 (52.5) | 337 (47.5) | 1 | |
| Yes | 60 (54.1) | 51 (45.9) | 0.94 (0.63–1.40) | |
| Depression (current) | ||||
| No ® | 407 (54.9) | 334 (45.1) | 1 | |
| Yes | 25 (31.6) | 54 (68.4) | 2.63 (1.60–4.32) | |
| Antenatal classes | ||||
| No ® | 111 (51.2) | 106 (48.8) | 1 | |
| Yes | 321 (53.2) | 282 (46.8) | 0.92 (0.67–1.26) | |
| High-risk pregnancy | ||||
| No ® | 364 (52.4) | 331 (47.6) | 1 | |
| Yes | 68 (54.4) | 57 (45.6) | 0.92 (0.63–1.35) | |
| Any illness (current) | ||||
| No ® | 388 (53.8) | 333 (46.2) | 1 | |
| Yes | 44 (44.4) | 55 (55.6) | 1.46 (0.95–2.22) | |
| Mental health issues (any time during life) | ||||
| No ® | 360 (58.4) | 256 (41.6) | 1 | 1 |
| Yes | 72 (35.3) | 132 (64.7) | 2.58 (1.86–3.58) | 1.77 (1.13–2.79) |
| Feeling tired during pregnancy, labor or postpartum | ||||
| No ® | 70 (82.4) | 15 (17.6) | 1 | |
| Yes | 362 (49.3) | 373 (50.7) | 4.81 (2.70–8.56) | |
| Type of birth | ||||
| Vaginal ® | 264 (54.5) | 220 (45.5) | 1 | |
| Instrumental | 86 (54.5) | 72 (45.6) | 1.01 (0.70–1.44) | |
| Cesarean section (elective) | 22 (48.9) | 23 (51.1) | 1.26 (0.68–2.31) | |
| Cesarean section (emergency) | 60 (45.1) | 73 (54.9) | 1.46 (0.99–2.15) | |
| Admission to ICU | ||||
| No ® | 427 (52.8) | 382 (47.2) | 1 | |
| Yes | 5 (45.5) | 6 (54.5) | 1.34 (0.41–4.43) | |
| Hospital readmission | ||||
| No ® | 420 (52.4) | 382 (47.6) | 1 | |
| Yes | 12 (66.7) | 6 (33.3) | 0.55 (0.20–1.48) | |
| Baby admission to pediatrics unit | ||||
| No ® | 390 (53.1) | 344 (46.9) | 1 | |
| Yes | 31 (46.3) | 36 (53.7) | 1.32 (0.80–2.17) | |
| Yes, NICU admission | 11 (57.9) | 8 (42.1) | 0.83 (0.33–2.07) | |
| Skin to Skin | ||||
| No ® | 52 (42.3) | 71 (57.7) | 1 | |
| Yes | 380 (54.5) | 317 (45.5) | 0.61 (0.42–0.90) | |
| Preterm baby | ||||
| No ® | 413 (52.8) | 369 (47.2) | 1 | |
| Yes | 19 (50.0) | 19 (50.0) | 1.12 (0.58–2.15) | |
| Early BF (1st hour) | ||||
| No ® | 74 (44.8) | 91 (55.2) | 1 | |
| Yes | 358 (54.7) | 397 (45.3) | 0.68 (0.48–0.95) | |
| Currently BF | ||||
| No ® | 47 (48.0) | 51 (52.0) | 1 | |
| Yes | 385 (53.3) | 337 (46.7) | 0.81 (0.53–1.23) | |
| Baby with problem (current) | ||||
| No ® | 406 (54.9) | 334 (45.1) | 1 | 1 |
| Yes | 26 (32.5) | 54 (67.5) | 2.52 (1.55–4.12) | 2.70 (1.34–5.47) |
| Experience during labor | ||||
| Bad or very bad ® | 35 (37.2) | 59 (62.8) | 1 | |
| Not sure | 73 (49.0) | 76 (51.0) | 0.62 (0.37–1.05) | |
| Good or very good | 324 (56.2) | 253 (43.8) | 0.46 (0.30–0.73) | |
| Experience (professional treatment) | ||||
| Bad or very bad ® | 12 (42.9) | 16 (57.1) | 1 | |
| Not sure | 26 (41.3) | 37 (58.7) | 1.07 (0.43–2.63) | |
| Good or very good | 394 (54.0) | 335 (46.0) | 0.64 (0.30–1.37) | |
| Support received from family | ||||
| Low or very low ® | 22 (31.9) | 47 (68.1) | 1 | |
| Moderate | 75 (46.9) | 85 (53.1) | 0.53 (0.29–0.96) | |
| High or very high | 335 (56.7) | 256 (43.3) | 0.36 (0.21–0.61) | |
| WAST (IPV risk) | ||||
| Low risk ® | 326 (60.0) | 217 (40.0) | 1 | 1 |
| High risk | 106 (38.3) | 171 (61.7) | 2.42 (1.80–3.26) | 1.53 (1.01–2.31) |
The backward stepwise procedure was used, and all variables from the bivariate analysis were included whether or not statistical significance was observed. For this analysis, the dependent variable GAD-7 was dichotomized, while the independent variables were entered into the model in their original form (age, the VAMF and EPDS scales continuously and without transformations or categorizations). ® reference categories.
Figure 1.
ROC curve for predictive capability for anxiety risk
When we compared no anxiety or mild anxiety and the presence of moderate or severe anxiety by performing bivariate and multivariate analyses to determine which factors were associated with these categories, a high EPDS score (AOR=1.35; 95% CI: 1.26–1.44) appeared as a risk factor. However, VAMF bonding score (AOR=0.92; 95% CI: 0.85–0.98), a monthly income level >2000 € (AOR=0.35; 95% CI: 0.15–0.80), and feeling well treated by healthcare professionals (AOR=0.21; 95% CI: 0.07–0.70) emerged as protective factors. The rest of the results of these analyses can be seen in Table 4. The predictive capability for moderate-severe anxiety risk had a AUC-ROC of 0.90 (95% CI: 0.88–0.93), with an exceptional capability to classify subjects according to the Swets criterion. The ROC curve can be seen in Figure 2.
Table 4.
Bivariable and multivariate analysis of the factors associated with no or mild anxiety and the presence of moderate or severe anxiety, on the GAD-7 questionnaire, Spain, 2021–2022 (N=820)
| Anxiety | ||||
|---|---|---|---|---|
|
No/mild
(GAD-7 <10) |
Moderate/severe
(GAD-7 ≥10) |
OR (95% CI) | AOR (95% CI) | |
| Variable | Mean (SD) | Mean (SD) | ||
| Age (years) | 34.30 (4.03) | 34.24 (4.28) | 1.00 (0.94–1.05) | |
| EPDS | 6.64 (4.03) | 13.76 (4.84) | 1.39 (1.31–1.47) | 1.35 (1.26–1.44) |
| VAMF bonding | 58.22 (3.48) | 54.59 (5.41) | 0.82 (0.78–0.87) | 0.92 (0.85–0.98) |
| VAMF attachment | 42.80 (4.74) | 42.05 (5.78) | 0.97 (0.93–1.01) | |
| Variable | n (%) | n (%) | ||
| Income level (€) | ||||
| <1000 ® | 116 (82.9) | 24 (17.1) | 1 | 1 |
| 1000–1999 | 395 (89.0) | 49 (11.0) | 0.60 (0.35–1.02) | 0.53 (0.27–1.04) |
| ≥2000 | 217 (91.9) | 19 (8.1) | 0.42 (0.22–0.81) | 0.35 (0.15–0.80) |
| Alcohol consumption | ||||
| Never ® | 235 (86.4) | 37 (13.6) | 1 | |
| Occasionally | 443 (90.0) | 49 (10.0) | 0.70 (0.45–1.11) | |
| Frequently | 50 (89.3) | 6 (10.7) | 0.76 (0.31–1.90) | |
| Smoking habit | ||||
| No ® | 662 (89.5) | 78 (10.5) | 1 | 1 |
| Yes | 66 (82.5) | 14 (17.5) | 1.80 (0.97–3.36) | 2.12 (0.97–5.05) |
| Number of children | ||||
| 1 ® | 538 (89.8) | 61 (10.2) | 1 | |
| 2 | 162 (84.8) | 29 (15.2) | 1.58 (0.98–2.54) | |
| ≥3 | 28 (93.3) | 2 (6.7) | 0.63 (0.15–2.71) | |
| Pregnancies | ||||
| 1 ® | 426 (88.6) | 55 (11.4) | 1 | |
| 2 | 199 (89.6) | 23 (10.4) | 0.90 (0.54–1.50) | |
| ≥3 | 102 (87.9) | 14 (12.1) | 1.06 (0.57–1.99) | |
| Planned pregnancy | ||||
| No ® | 62 (83.8) | 12 (16.2) | 1 | |
| Yes | 666 (89.3) | 80 (10.7) | 0.62 (0.32–1.20) | |
| Cesarean birth (previous) | ||||
| No ® | 546 (89.8) | 62 (10.2) | 1 | |
| Yes | 182 (85.8) | 30 (14.2) | 1.45 (0.91–2.32) | |
| Fertility treatment (IVF, egg donation, | ||||
| etc.) | ||||
| No ® | 630 (88.9) | 79 (11.1) | 1 | |
| Yes | 98 (88.3) | 13 (11.7) | 1.06 (0.57–1.97) | |
| Depression (current) | ||||
| No ® | 668 (90.1) | 73 (9.9) | 1 | |
| Yes | 60 (75.9) | 19 (24.1) | 2.90 (1.64–5.12) | |
| Antenatal classes | ||||
| No ® | 194 (89.4) | 23 (10.6) | 1 | |
| Yes | 534 (88.6) | 69 (11.4) | 1.09 (0.66–1.80) | |
| High-risk pregnancy | ||||
| No ® | 617 (88.8) | 78 (11.2) | 1 | |
| Yes | 111 (88.8) | 14 (11.2) | 1.00 (0.55–1.83) | |
| Any illness (current) | ||||
| No ® | 649 (90.0) | 72 (10.0) | 1 | |
| Yes | 79 (79.8) | 20 (20.2) | 2.28 (1.32–3.95) | |
| Mental health issues (any time during life) | ||||
| No ® | 562 (91.2) | 54 (8.8) | 1 | |
| Yes | 166 (81.4) | 38 (18.6) | 2.38 (1.52–3.74) | |
| Feeling tired during pregnancy, labor or postpartum | ||||
| No ® | 85 (100.0) | 0 (0.0) | 1 | |
| Yes | 643 (87.5) | 92 (12.5) | Not calculated | |
| Type of birth | ||||
| Vaginal ® | 436 (90.1) | 48 (9.9) | 1 | |
| Instrumental | 140 (88.6) | 18 (11.4) | 1.17 (0.66–2.07) | |
| Cesarean section (elective) | 41 (91.1) | 4 (8.9) | 0.89 (0.30–2.58) | |
| Cesarean section (emergency) | 111 (83.5) | 22 (16.5) | 1.80 (1.04–3.11) | |
| Admission to ICU | ||||
| No ® | 720 (89.0) | 89 (11.0) | 1 | |
| Yes | 8 (72.7) | 3 (27.3) | 3.03 (0.79–11.65) | |
| Hospital readmission | ||||
| No ® | 714 (89.0) | 88 (11.0) | 1 | |
| Yes | 14 (77.8) | 4 (22.2) | 2.32 (0.75–7.20) | |
| Baby admission to pediatrics unit | ||||
| No ® | 651 (88.7) | 83 (11.3) | 1 | |
| Yes | 60 (89.6) | 7 (10.4) | 0.92 (0.41–2.07) | |
| Yes, NICU admission | 17 (89.5) | 2 (10.5) | 0.92 (0.21–4.07) | |
| Skin to Skin | ||||
| No ® | 99 (80.5) | 24 (19.5) | 1 | |
| Yes | 629 (90.2) | 68 (9.8) | 0.45 (0.27–0.74) | |
| Preterm baby | ||||
| No ® | 695 (88.9) | 87 (11.1) | 1 | |
| Yes | 33 (86.8) | 5 (13.2) | 1.21 (0.46–3.18) | |
| Early BF (1st hour) | ||||
| No ® | 139 (84.2) | 26 (15.8) | 1 | |
| Yes | 589 (89.9) | 66 (10.1) | 0.60 (0.37–0.98) | |
| Currently BF | ||||
| No ® | 81 (82.7) | 17 (17.3) | 1 | |
| Yes | 647 (89.6) | 75 (10.4) | 0.55 (0.31–0.98) | |
| Baby with problem (current) | ||||
| No ® | 665 (89.9) | 75 (10.1) | 1 | |
| Yes | 63 (78.8) | 17 (21.3) | 2.39 (1.33–4.30) | |
| Experience during labor | ||||
| Bad or very bad ® | 70 (74.5) | 24 (25.5) | 1 | 1 |
| Not sure | 134 (89.9) | 15 (10.1) | 0.33 (0.16–0.66) | 0.43 (0.17–1.09) |
| Good or very good | 524 (90.8) | 53 (9.2) | 0.30 (0.17–0.51) | 1.22 (0.52–2.82) |
| Experience (professional treatment) | ||||
| Bad or very bad ® | 20 (71.4) | 8 (28.6) | 1 | 1 |
| Not sure | 48 (76.2) | 15 (23.8) | 0.78 (0.29–2.13) | 0.68 (0.19–2.46) |
| Good or very good | 660 (90.5) | 69 (9.5) | 0.26 (0.11–0.62) | 0.21 (0.07–0.70) |
| Support received from family | ||||
| Low or very low ® | 50 (72.5) | 19 (27.5) | 1 | |
| Moderate | 140 (87.5) | 20 (12.5) | 0.38 (0.19–0.76) | |
| High or very high | 538 (91.0) | 53 (9.0) | 0.26 (0.14–0.47) | |
| WAST (IPV risk) | ||||
| Low risk ® | 496 (91.3) | 47 (8.7) | 1 | |
| High risk | 232 (83.8) | 45 (16.2) | 2.05 (1.32–3.17) | |
The backward stepwise procedure was used, and all variables from the bivariate analysis were included whether or not statistical significance was observed. For this analysis, the dependent variable GAD-7 was dichotomized, while the independent variables were entered into the model in their original form (age, the VAMF and EPDS scales continuously and without transformations or categorizations). ® Reference categories.
Figure 2.
ROC curve for predictive capability for moderate-severe anxiety risk
DISCUSSION
The study found that nearly 50% of women experienced some level of anxiety postpartum, with over 30% reported mild anxiety, 8% moderate, and nearly 3% severe anxiety. Factors increasing the likelihood of anxiety included higher EPDS scores, smoking, a history of mental health issues, positive WAST results, and having a baby with current problems. In contrast, protective factors against anxiety included strong bonding (VAMF), feeling well-treated by healthcare professionals, and having a moderate to high monthly income, particularly for moderate or severe anxiety.
The prevalence of anxiety detected in our study is slightly higher than that found by other studies, where the prevalence does not exceed 42%4-6. Fawcett et al.5 found in their systematic review with meta-analysis that 2 in 10 women suffer from postpartum anxiety. Likewise, Dennis et al.26, who differentiated between symptoms and the presence of an anxiety diagnosis, also found a lower prevalence than in our population and coincides with those of other authors4. This may be due to the tools used. The GAD-7, which has been used in this study, represents a tool that is easy to administer to establish a rapid screening for anxiety in perinatal populations27.
Women with higher EPDS scores suffer more frequently from postpartum anxiety, which is in line with different studies7,12,16. Sit et al.12 found in their study with 628 women, that at least 1 in 2 women has depression and also anxiety as a second diagnosis. Similarly, 41% of women with anxiety had depressive disorders as a second diagnosis. Both pathologies can coexist in such a way that the presence of one of them favors the development of the other28-30. Anxiety remains one of the most important risk factors for postpartum depression, highlighting the need for effective screening for its possible presence at multiple points in time31,32.
Smoking causes mood swings that can be conducive to the onset of anxiety33. Munafo et al.34 found an association between depressive symptoms and smoking, with a large proportion of women facing both depression and anxiety, and these two conditions are often interrelated28-30.
Mothers whose babies had a problem were more likely to suffer from anxiety, which is in line with other studies35,36. Support from healthcare professionals is crucial, especially if newborns are admitted to hospital. Indeed, the proper treatment by health professionals involved in postpartum care emerged as a protective factor against anxiety. Zhou et al.37 found in their systematic review with meta-analysis where they identified a total of 11 studies and a sample of 2424 women from six different countries, that this is crucial for positive effects on maternal mental health. Women’s experiences would improve if they were given the opportunity to establish a trusting relationship with health professionals38.
Poor partner relationships and even abuse have been shown to be a variable recurrently associated with the onset of anxiety, postpartum depression, and even perinatal suicide11,17 which coincides with our findings. Women consider the emotional and practical support of their partners to be fundamental to mitigating anxiety38 although there are researchers who found opposite results, with the role of the partner being of little importance and not being associated with the presence of anxiety39.
If mothers had experienced a mental health problem during their lifetime, they were more likely to suffer from anxiety, which is in line with other authors40.
The mother–baby bond acts as a protective factor for the development of anxiety during the postpartum period, something that has been found by other authors41. Figueiredo and Costa42 found that anxiety is associated with poorer bonding, which may produce strong negative emotions toward the baby and less emotional involvement with the baby. This can have implications for the cognitive and physiological development of the newborn at an estimated cost of almost £6 billion43.
Several authors found that socioeconomic status plays an important role in increasing the risk of anxiety in women who do not have the resources to meet their financial needs11,44,45. This is in line with our findings that having a moderate/high monthly income protects against the possibility of postpartum anxiety.
Strengths and limitations
The cross-sectional nature of this study limits the ability to draw causal inferences between the identified risk factors and postpartum anxiety. However, this limitation also presents an opportunity for further research in this area. While many of the assessment tools employed were self-reported questionnaires, the presence of a trained midwife or healthcare professional during the completion of these questionnaires helped to minimize potential bias. Consideration should be given to the temporal context of data collection and its potential impact on mental health outcomes in future studies. Enhancing the diversity of samples, including participants from various regions or countries, could improve the reliability of the findings. The questions were designed to be comprehensible across varying educational levels, thereby reducing the likelihood of classification bias. Furthermore, the sample was representative of the target population, with the mean age of participants aligning with the national mean maternal age in the country where the research was conducted. Although recall bias was a consideration, it is unlikely to have significantly affected the results, as the information solicited pertained to recent and salient experiences that would be difficult for participants to forget. One of the primary strengths of the study lies in the use of tools that have been specifically validated and adapted for the population studied, thereby enhancing the relevance and applicability of the findings.
CONCLUSIONS
The present study shows that a high percentage of women experience anxiety, with a notable prevalence of mild anxiety, and a significant number facing moderate and severe levels. Factors such as a history of mental health problems, smoking, and baby-related complications increase the risk of developing anxiety, while strong bonding, adequate care from health professionals, and a stable economic situation seem to offer greater protection against this condition. Knowledge of risk factors will help health professionals providing care to postpartum women to recognize warning signs, enabling early detection and care.
ACKNOWLEDGEMENTS
We thank all the women who participated in this study.
Funding Statement
FUNDING There was no source of funding for this research.
CONFLICTS OF INTEREST
The authors have completed and submitted the ICMJE Form for disclosure of Potential Conflicts of Interest and none was reported.
ETHICAL APPROVAL AND INFORMED CONSENT
Ethical approval was obtained from the Research Ethics Committee of the Province of Jaén (Approval number: DCVA-21/2012-N-21; Date: 25 November 2021). Participants provided informed consent.
DATA AVAILABILITY
The data supporting this research are available from the authors on reasonable request.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
REFERENCES
- 1.Hertle D, Petrautzki I, Wende D. Macht Mutterwerden krank? - Häufigkeit psychischer Diagnosen bei Müttern nach der Geburt im Vergleich zu kinderlosen Frauen auf Basis von BARMER-Abrechnungsdaten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2024;67(12):1325-1333. doi: 10.1007/s00103-024-03969-4 [DOI] [PubMed] [Google Scholar]
- 2.Alnaji N, Louis B, Bagenda D. Understanding risk factors for perinatal distress in Syrian refugee mothers: insights from Lebanon. Arch Womens Ment Health. 2025;28(2):271-278. doi: 10.1007/s00737-024-01544-z [DOI] [PubMed] [Google Scholar]
- 3.American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed. American Psychiatric Association; 2022. doi: 10.1176/appi.books.9780890425787 [DOI] [Google Scholar]
- 4.Remes O, Brayne C, van der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav. 2016;6(7):e00497. doi: 10.1002/brb3.497 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis. J Clin Psychiatry. 2019;80(4):18r12527. doi: 10.4088/JCP.18r12527 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Costa R, Mesquita A, Motrico E, et al. Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic. Acta Psychiatr Scand. 2024;150(5):474-491. doi: 10.1111/acps.13664 [DOI] [PubMed] [Google Scholar]
- 7.Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affect Disord. 2016;191:62-77. doi: 10.1016/j.jad.2015.11.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Peter PJ, de Mola CL, de Matos MB, et al. Association between perceived social support and anxiety in pregnant adolescents. Braz J Psychiatry. 2017;39(1):21-27. doi: 10.1590/1516-4446-2015-1806 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Dennis CL, Brown HK, Falah-Hassani K, Marini FC, Vigod SN. Identifying women at risk for sustained postpartum anxiety. J Affect Disord. 2017;213:131-137. doi: 10.1016/j.jad.2017.02.013 [DOI] [PubMed] [Google Scholar]
- 10.Furtado M, Chow CHT, Owais S, Frey BN, Van Lieshout RJ. Risk factors of new onset anxiety and anxiety exacerbation in the perinatal period: A systematic review and meta-analysis. J Affect Disord. 2018;238:626-635. doi: 10.1016/j.jad.2018.05.073 [DOI] [PubMed] [Google Scholar]
- 11.Jimènez-Barragan M, Falguera-Puig G, Curto-Garcia JJ, et al. Prevalence of anxiety and depression and their associated risk factors throughout pregnancy and postpartum: a prospective cross-sectional descriptive multicentred study. BMC Pregnancy Childbirth. 2024;24(1):500. doi: 10.1186/s12884-024-06695-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Sit D, Luther J, Buysse D, et al. Suicidal ideation in depressed postpartum women: Associations with childhood trauma, sleep disturbance and anxiety. J Psychiatr Res. 2015;66-67:95-104. doi: 10.1016/j.jpsychires.2015.04.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rogers A, Obst S, Teague SJ, et al. Association Between Maternal Perinatal Depression and Anxiety and Child and Adolescent Development: A Meta-analysis. JAMA Pediatr. 2020;174(11):1082-1092. doi: 10.1001/jamapediatrics.2020.2910 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Tietz A, Zietlow AL, Reck C. Maternal bonding in mothers with postpartum anxiety disorder: the crucial role of subclinical depressive symptoms and maternal avoidance behaviour. Arch Womens Ment Health. 2014;17(5):433-442. doi: 10.1007/s00737-014-0423-x [DOI] [PubMed] [Google Scholar]
- 15.Anniverno R, Bramante A, Mencacci C, Durbano F. Anxiety Disorders in Pregnancy and the Postpartum Period. In: Durbano F, ed. New Insights into Anxiety Disorders. InTech; 2013. doi: 10.5772/52786 [DOI] [Google Scholar]
- 16.Gavin NI, Meltzer-Brody S, Glover V, Gaynes BN. Is population-based identification of perinatal depression and anxiety desirable? A public health perspective on the perinatal depression care continuum. In: Milgrom J, Gemmill AW, eds. Identifying perinatal depression and anxiety: Evidence-based practice in screening, psychosocial assessment, and management. Wiley; 2015:11-31. doi: 10.1002/9781118509722 [DOI] [Google Scholar]
- 17.Martínez-Galiano JM, Martínez-Vázquez S, Peinado-Molina RA, Hernández-Martínez A. Validation of the Paykel Suicide Scale and the Plutchik Suicide Risk Scale in Spanish Women during the Perinatal Period. Depress Anxiety. 2024;2024:3741489. doi: 10.1155/2024/3741489 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Martínez-Vázquez S, Peinado-Molina RA, Hernández-Martínez A, Martínez-Galiano JM. Prevalence and Associated Factors of Perinatal Suicide Risk in Spanish Women. Arch Suicide Res. doi: 10.1080/13811118.2024.2353175 [DOI] [PubMed] [Google Scholar]
- 19.Edwards RT, Lawrence CL. Health Economics of Well-being and Well-becoming across the Life-course. Oxford University Press; 2024. [Google Scholar]
- 20.Gómez-Gómez I, Domínguez-Salas S, Rodríguez-Muñoz MF, Rodríguez-Domínguez C, Gómez-Baya D, Motrico E. Psychometric Properties of the Online Version of the General Anxiety Disorder-7 (GAD-7): A Longitudinal Study in Pregnant and Postpartum Spanish Women. Psicothema. 2024;36(3):227-235. doi: 10.7334/psicothema2023.293 [DOI] [PubMed] [Google Scholar]
- 21.Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373-1379. doi: 10.1016/s0895-4356(96)00236-3 [DOI] [PubMed] [Google Scholar]
- 22.Diaz-Ogallar MA, Hernandez-Martinez A, Linares-Abad M, Martinez-Galiano JM. Design and Validation of an Instrument for the Evaluation of the Quality of Mother-Child Bond and Attachment: “Cuestionario Vínculo y Apego Materno-Filial” (VAMF Questionnaire). J Nurs Manag. 2024;2024:6384511. doi: 10.1155/2024/6384511 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Vega-Dienstmaier J, Mazzotti Suárez G, Campos Sánchez M. Validación de una versión en español de la Escala de Depresión Postnatal de Edimburgo. Actas Españolas de Psiquiatría. 2002;30(2):106-111. [PubMed] [Google Scholar]
- 24.Plazaola-Castaño J, Ruiz-Pérez I, Hernández-Torres E. Validación de la versión corta del Woman Abuse Screening Tool para su uso en atención primaria en España. Gac Sanit. 2008;22(5):415-420. doi: 10.1157/13126922 [DOI] [PubMed] [Google Scholar]
- 25.Swets JA. Measuring the accuracy of diagnostic systems. Science. 1988;240(4857):1285-1293. doi: 10.1126/science.3287615 [DOI] [PubMed] [Google Scholar]
- 26.Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry. 2017;210(5):315-323. doi: 10.1192/bjp.bp.116.187179 [DOI] [PubMed] [Google Scholar]
- 27.Simpson W, Glazer M, Michalski N, Steiner M, Frey BN. Comparative efficacy of the generalized anxiety disorder 7-item scale and the Edinburgh Postnatal Depression Scale as screening tools for generalized anxiety disorder in pregnancy and the postpartum period. Can J Psychiatry. 2014;59(8):434-440. doi: 10.1177/070674371405900806 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Heron J, O’Connor TG, Evans J, Golding J, Glover V; ALSPAC Study Team . The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80(1):65-73. doi: 10.1016/j.jad.2003.08.004 [DOI] [PubMed] [Google Scholar]
- 29.Bradshaw H, Riddle JN, Salimgaraev R, Zhaunova L, Payne JL. Risk factors associated with postpartum depressive symptoms: A multinational study. J Affect Disord. 2022;301:345-351. doi: 10.1016/j.jad.2021.12.121 [DOI] [PubMed] [Google Scholar]
- 30.Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord. 2005;19(3):295-311. doi: 10.1016/j.janxdis.2004.04.001 [DOI] [PubMed] [Google Scholar]
- 31.Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD; DEPRESsion Screening Data (DEPRESSD) EPDS Group . Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ. 2020;371:m4022. doi: 10.1136/bmj.m4022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Wu D, Jiang L, Zhao G. Additional evidence on prevalence and predictors of postpartum depression in China: A study of 300,000 puerperal women covered by a community-based routine screening programme. J Affect Disord. 2022;307:264-270. doi: 10.1016/j.jad.2022.04.011 [DOI] [PubMed] [Google Scholar]
- 33.Diamanti A, Papadakis S, Schoretsaniti S, et al. Smoking cessation in pregnancy: An update for maternity care practitioners. Tob Induc Dis. 2019;17(August):1-14. doi: 10.18332/tid/109906 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Munafò MR, Heron J, Araya R. Smoking patterns during pregnancy and postnatal period and depressive symptoms. Nicotine Tob Res. 2008;10(11):1609-1620. doi: 10.1080/14622200802412895 [DOI] [PubMed] [Google Scholar]
- 35.Lefkowitz DS, Baxt C, Evans JR. Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive Care Unit (NICU). J Clin Psychol Med Settings. 2010;17(3):230-237. doi: 10.1007/s10880-010-9202-7 [DOI] [PubMed] [Google Scholar]
- 36.Roca-Lecumberri A, Torres A, Andrés S, et al. Treating postpartum affective and/or anxiety disorders in a mother-baby day hospital: preliminary results. Int J Psychiatry Clin Pract. 2023;27(4):344-350. doi: 10.1080/13651501.2023.2236169 [DOI] [PubMed] [Google Scholar]
- 37.Zhou C, Hu H, Wang C, et al. The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis. J Telemed Telecare. 2022;28(2):83-95. doi: 10.1177/1357633X20917816 [DOI] [PubMed] [Google Scholar]
- 38.Meades R, Moran PM, Hutton U, et al. Acceptability of identification and management of perinatal anxiety: a qualitative interview study with postnatal women. Front Public Health. 2024;12:1466150. doi: 10.3389/fpubh.2024.1466150 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Daehn D, Rudolf S, Pawils S, Renneberg B. Perinatal mental health literacy: knowledge, attitudes, and help-seeking among perinatal women and the public - a systematic review. BMC Pregnancy Childbirth. 2022;22(1):574. doi: 10.1186/s12884-022-04865-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Astbury L, Pinnington DM, Milgrom J, Bei B. The longitudinal trajectory of depression and anxiety across the perinatal period. J Affect Disord. 2024;370:1-8. doi: 10.1016/j.jad.2024.10.080 [DOI] [PubMed] [Google Scholar]
- 41.Díaz-Ogallar MA, Hernández-Martínez A, Linares-Abad M, Martínez-Galiano JM. Development of a Predictive Model for Skin-to-Skin Contact Immediately after Birth: A Cross-Sectional Study. Children. 2024;11(5):577. doi: 10.3390/children11050577 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Figueiredo B, Costa R. Mother’s stress, mood and emotional involvement with the infant: 3 months before and 3 months after childbirth. Arch Womens Ment Health. 2009;12(3):143-153. doi: 10.1007/s00737-009-0059-4 [DOI] [PubMed] [Google Scholar]
- 43.Ayers S, Coates R, Sinesi A, et al. Assessment of perinatal anxiety: diagnostic accuracy of five measures. Br J Psychiatry. 2024;224(4):132-138. doi: 10.1192/bjp.2023.174 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Verbeek T, Bockting CLH, Beijers C, Meijer JL, van Pampus MG, Burger H. Low socioeconomic status increases effects of negative life events on antenatal anxiety and depression. Women Birth. 2019;32(1):e138-e143. doi: 10.1016/j.wombi.2018.05.005 [DOI] [PubMed] [Google Scholar]
- 45.Best C, Ayers S, Sinesi A, et al. Socioeconomic deprivation and perinatal anxiety: an observational cohort study. BMC Public Health. 2024;24(1):3183. doi: 10.1186/s12889-024-20608-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this research are available from the authors on reasonable request.