Abstract
Introduction
The coronavirus disease 2019 (COVID‐19) pandemic has intensified perinatal anxiety disorders. Psychological flexibility (PF), considered a specific mental toughness, has not been examined with regard to its relationship with anxiety in women after childbirth. We aimed to compare levels of anxiety, PF, and pain in women depending on the mode of birth, parity, and the magnitude of risk of developing an anxiety disorder. We also investigated the association of anxiety with PF and pain.
Methods
A total of 187 women after childbirth completed validated questionnaires for anxiety (State‐Trait Anxiety Inventory, Hospital Anxiety and Depression Scale‐Anxiety, Numerical Rating Scale for anxiety [NRS‐A]), PF, and pain (Numerical Rating Scale for pain). Specific postpartum anxieties were assessed with a numerical scale from 0 to 10. The relationship of anxiety with PF and pain was examined. Women at low and high risk of developing anxiety disorder were compared in terms of PF, anxiety, and pain.
Results
On the second postpartum day, women after cesarean birth demonstrated significantly greater anxiety on NRS‐A and pain than those after vaginal birth. Primiparous women experienced significantly greater anxieties and pain compared to multiparous women. The higher the PF patients demonstrated, the less anxiety and pain they had. Patients at high risk of developing an anxiety disorder had a lower level of PF (P < .001) and higher levels of anxiety (P < .001) and pain (P < .01) than patients at low risk of developing an anxiety disorder. No difference in the anxiety of getting COVID‐19 was observed between the groups (P > .05).
Conclusions
PF is an important psychological construct related to the mental and physical condition of women after childbirth. Increasing PF in women after childbirth may be considered as an important goal of preventive and intervention measures.
Keywords: anxiety, psychological flexibility, pain, puerperium, rooming‐in
INTRODUCTION
Psychological flexibility (PF) appears to be a specific mental toughness of an individual, thus having a overall impact on his or her health. Psychological inflexibility (PI) is the opposite of PF and is associated with many forms of psychopathology. 1 PF is defined as an accepting, open, and conscious attitude, in which one is in contact with the present moment and contact with one's emotions, impressions, and thoughts. High PF is related to the ability of an individual to freely choose an action whose direction is consistent with the goals and long‐term values, even under conditions of experienced discomfort. Conversely, PI is related to not accepting difficult thoughts and emotions, which leads to the avoidance of experiencing them as a way to control internal events, often resulting in an impulsive short‐term departure from important life values. It also is based on the dominance of psychological reactions over chosen values in actions and attitudes. PF consists of 6 processes: acceptance, cognitive defusion, flexible contact with the present moment, self as context, values, and committed action. 2 , 3 PF has its source in contextual behavioral science, the aim of which is to scientifically predict behavior in a specific context, as well as the possibility of modifying it. 4 , 5
QUICK POINTS
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Psychological flexibility (PF) is an important psychological construct related to the mental and physical condition of women after childbirth.
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The higher PF patients show after childbirth, the less anxiety and pain they experience.
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First‐time mothers had higher levels of anxiety of caring for a newborn and of the newborn crying.
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The levels of PF, trait anxiety, and anxiety of getting COVID‐19 did not differ significantly between women with different modes of birth and parity.
Acceptance and commitment therapy (ACT) focuses on increasing the level of PF, influencing the improvement of the adaptive functioning of the individual. 2 Research shows that ACT is effective in the improvement of quality of life and psychological well‐being, as well as promoting healthy behavior among patients with somatic and psychological disorders. 6 , 7 , 8 , 9 , 10 , 11 ACT assumes that suffering, fear, pain, and loss are inherent elements of human life. They do not disturb the actions of a person following the values chosen in life if the person can react to them with acceptance, openness, and mindfulness. 2 For example, studies have shown that higher PF is associated with better well‐being in people with obesity and after trauma, as well as higher quality of life and functioning of people with diabetes. 12 , 13 , 14 PF is also a mediator that has a protective function against the risk of developing depression in new mothers of premature newborns. 15
On the other hand, numerous studies have shown that the psychological condition of women after childbirth is related to perceived anxiety 16 , 17 , 18 and co‐occurring pain. 19 The frequency of anxiety disorders is higher than that of depressive disorders. 20 A high level of pain and anxiety may limit a woman's mobility and ability to care for a newborn 21 , 22 ; for this reason, researchers seek predictors of perinatal pain and anxiety. 23 , 24 , 25
A high level of pain and anxiety may limit the functioning of women in the rooming‐in unit. Rooming‐in is a system that allows the newborn to stay in the same room with the mother for 24 hours a day. 26 A woman, with the support of the staff, can carry out most of the nursing activities for the newborn on her own. A study conducted among Polish women staying in the rooming‐in unit showed that postpartum pain, anxiety disorders, and the lack of support from visitors during the coronavirus disease 2019 (COVID‐19) pandemic contributed to the deterioration of the psychological condition of women after childbirth. 27 A meta‐analysis showed that during the COVID‐19 pandemic, an increase in depressive and anxiety symptoms in pregnant women was observed. 28 Studies performed in various countries during the COVID‐19 pandemic showed that PF was related to better mental and physical functioning as well as better well‐being of people during lockdown. 29 , 30 , 31 In some studies, a measure of people's well‐being is the association between higher PF and lower levels of perceived anxiety and pain. 32 , 33 , 34 , 35 , 36 In Poland, partners can participate in newborn care; however, during the COVID pandemic, partners were not allowed in rooming‐in units. Restricted visitation likely increased the anxiety of women in rooming‐in units; however, the relationship between anxiety and PF during this time has not been studied.
The primary goal of this study was to explore the relationship between PF and anxiety in women in the rooming‐in unit during the COVID‐19 pandemic. A secondary goal was to test whether variables such as PF, anxiety (measured with questionnaires other than Hospital Anxiety and Depression Scale‐Anxiety [HADS‐A]), and pain could predict anxiety disorder risk.
METHODS
Population and Settings
The study was conducted in the obstetric ward functioning in the rooming‐in system in a tertiary hospital, the University Teaching Hospital, Wrocław, Poland. This tertiary hospital has a cesarean birth (CB) rate of approximately 50%, similar to other centers with the same level of care. The overall incidence of CB is 42% in Poland. 37 The study included 200 white women 18 years and older staying with their newborns in this ward on the second day (48‐72 hours) after birth. Inclusion criteria were adult women who gave birth at term (≥37 weeks’ gestation), Apgar score ≥ 8, CB or vaginal birth (VB), and stable postpartum condition (absence of drains, catheters, or abnormal postpartum blood loss). Exclusion criteria were unstable postpartum condition (presence of drains, catheters, or postpartum hemorrhage) and history of a psychiatric disorder. The patients’ level of anxiety, PF, level of pain, and demographics were assessed by self‐report.
The data were collected from December 2020 to April 2021. Missing data were present in 13 of 200 enrolled participants; therefore, the final sample was 187 women.
The study was confidential. All patients gave written informed consent to participate in the study. The study was approved by the Commission of Bioethics at Wroclaw Medical University, Poland (KB – 747/2020).
Scales
Anxiety Measurement
There is a distinction between anxiety as a temporary, transient emotional state (state anxiety) and anxiety understood as a persistent, permanent personality trait, expressed in the readiness to react with anxiety in certain situations: anxiety as a trait (trait anxiety).
HADS‐A
The Polish adaptation of the Hospital Anxiety and Depression Scale developed by Zigmond and Snaith 38 enables an assessment of the level of anxiety and depression of patients in a hospital setting during the past week (state anxiety). 39 Anxiety can be assessed using an independent subscale—the HADS‐A, consisting of 7 questions. Each question is scored from 0 to 3 points that sum up to 21 points. Scores greater than 10 denote increased risk of anxiety disorder. 40
State‐Trait Anxiety Inventory
The Polish adaptation of the State‐Trait Anxiety Inventory (STAI) consists of 2 separate scales: X‐1 for anxiety as a state (STAI‐S) and X‐2 for anxiety as a trait (STAI‐T). 41 , 42 Both scales include 20 questions. The total score ranges from a minimum of 20 to a maximum of 80. The higher the total score, the higher the anxiety level.
Numerical Rating Scale for Anxiety
The Numerical Rating Scale for Anxiety (NRS‐A) ranges from 0 to 10 (0 denotes no anxiety, 10 denotes the most severe anxiety imaginable). The scale is used to measure state anxiety. Despite its simplicity, it is valid and reliable. 43 , 44
Specific Postpartum Anxiety Scales
Additionally, patients were asked to provide subjective levels of specific anxiety, also rated from 0 to 10. The scales included questions about the anxiety of self‐care for a newborn during the day, the anxiety of self‐care for a newborn at night, the anxiety of a newborn crying, and anxiety of getting COVID‐19.
PF Measurement
Acceptance and Action Questionnaire‐2
PF was measured using the Acceptance and Action Questionnaire‐2 (AAQ‐2). 45 , 46 AAQ‐2 consists of 7 statements such as “I'm afraid of my feelings,” and “Emotions cause problems in my life.” AAQ‐2 examines the most common tendency to avoid experiencing in adult life. The answers are given on a 7‐point scale (from 1: never true to 7: always true) and sum up to a total score ranging from 7 to 49. Higher scores indicate lower PF (PI). In the description of our research, lower values of the AAQ‐2 questionnaire are marked as PF, whereas higher values are marked as PI. Cronbach's α for AAQ‐2 was 0.857.
Pain Measurement
The Numerical Rating Scale for pain (NRS) ranges from 0 to 10 (0 denotes no pain, 10 denotes the most severe pain imaginable). It is commonly used in clinical practice to measure pain. Despite its simplicity, it has been shown to be valid and reliable. 47
Study Protocol
After giving their informed consent to participate in the study, patients were asked to complete the following questionnaires: STAI‐T, AAQ‐2, NRS, NRS‐A, STAI‐S, HADS‐A, and specific postpartum anxiety scales.
Statistical Analysis
Statistical analysis was conducted using IBM SPSS Statistics 26 (IBM Corp, Armonk, NY). All the variables showed significant discrepancies from the normal distribution. Independent groups were compared using the Mann‐Whitney U test. Correlations were evaluated with Spearman's ρ coefficient. One‐way logistic regression (Nagelkerke's R2 ) and receiver operating characteristic (ROC) analysis were used to predict the risk of an anxiety disorder. The significance of the measurements was assumed for the value of P < .05.
The sample size was estimated using the G* power package. 48 A priori, the Mann‐Whitney U test (2 groups) with an average effect size of d = 0.50, with power (1 − β) of 0.95 and with a probability level of α = 0.05, was used. For these assumptions, the groups should have 92 people each (a total sample size of at least 184).
RESULTS
The mean age of the group of 187 patients was 32 years (range, 22‐43 years). Most of the patients declared higher education (83.4%), good financial situation (88.8%), and living in a formal relationship (78.6%). More than half of the women (56.1%) gave birth by CB, and 43.9% gave birth naturally. Overall, 49.7% of participants were primiparous women, whereas 50.3% were multiparous women (Table 1).
Table 1.
Demographic Characteristics of Women in the Rooming‐in Unit (N = 187)
| Characteristic | Value, n (%) |
|---|---|
| Parity | |
| 1 | 93 (49.7) |
| 2 | 82 (43.9) |
| 3 | 10 (5.3) |
| 4 | 2 (1.1) |
| Mode of birth | |
| Vaginal birth | 82 (43.9) |
| Cesarean birth | 105 (56.1) |
| Gestational age | |
| 37 wk | 16 (8.6) |
| 38 wk | 56 (29.9) |
| 39 wk | 56 (29.9) |
| 40 wk | 36 (19.3) |
| 41 wk | 22 (11.8) |
| 42 wk | 1 (0.5) |
| Education | |
| University | 156 (83.4) |
| Secondary | 17 (9.1) |
| Vocational | 10 (5.3) |
| Lower secondary | 3 (1.6) |
| Primary | 1 (0.5) |
| Financial situation | |
| Good | 166 (88.8) |
| Moderate | 19 (10.2) |
| Poor | 2 (1.1) |
| Marital status | |
| Formal relationship (married) | 147 (78.6) |
| Informa relationship (partnership) | 31 (16.6) |
| Single | 9 (4.8) |
Internal Consistency of the Scales Used
Cronbach's α for the HADS‐A in this study was .83. We defined the group of patients who scored ≤10 on HADS‐A as being at low risk of developing an anxiety disorder, whereas a group of patients who scored >10 was defined as being at high risk of developing an anxiety disorder. Cronbach's α for the STAI was .96 for state anxiety and .85 for trait anxiety. Cronbach's α for AAQ‐2 was .86.
Comparison of Patients by Mode of Birth and Parity
Patients reported greater pain after CB than after VB (P < .01) and higher anxiety using the NRS‐A scale after CB than after VB (P < .05). There was no significant difference (P > .05) in the levels of trait anxiety, hospital anxiety (HADS‐A), state anxiety (on the STAI‐S scale), specific postpartum anxiety, or PF by mode of birth. Primiparous women reported higher levels of anxiety (on the STAI‐S, NRS‐A, HADS‐A, and anxieties related to care of the newborn and crying) and pain than multiparous women. There was no significant difference between primiparous and multiparous women with respect to levels of trait anxiety, anxiety of getting COVID‐19, and PF (Table 2).
Table 2.
Comparison of Mood by Mode of Birth and Parity for Women in the Rooming‐in Unit (N = 187)
| Median (IQR) | Median, IQR, Mean Rank | Median, IQR, Mean Rank | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Questionnaire | Total (N = 187) | Vaginal Birth (n = 82) | Cesarean Birth (n = 105) | U (Z) | P Value | Primiparous (n = 93) | Multiparous (n = 94) | U (Z) | P Value |
| AAQ‐2 | 16.00 (9.00) | 16.00 | 16.00 | 0.662 | .508 | 16.00 | 15.50 | 0.100 | .920 |
| 10.00 | 9.00 | 8.00 | 10.00 | ||||||
| 91.04 | 96.31 | 93.60 | 94.39 | ||||||
| STAI‐T | 37.00 (10.00) | 37.00 | 38.00 | 0.568 | .570 | 37.00 | 37.50 | 0.285 | .775 |
| 9.25 | 9.00 | 9.00 | 11.00 | ||||||
| 91.46 | 95.99 | 92.87 | 95.12 | ||||||
| STAI‐S | 42.00 (17.00) | 42.00 | 42.00 | 1.065 | .287 | 42.00 | 40.00 | 2.367 | .018 |
| 20.50 | 16.00 | 17.00 | 18.00 | ||||||
| 89.23 | 97.72 | 103.41 | 84.69 | ||||||
| NRS‐A | 3.00 (3.00) | 3.00 | 3.00 | 2.038 | .042 | 4.00 | 2.00 | 4.321 | <.001 |
| 4.00 | 4.00 | 4.00 | 3.25 | ||||||
| 84.94 | 101.08 | 111.07 | 77.11 | ||||||
| HADS‐A | 7.00 (6.00) | 6.00 | 7.00 | 1.317 | .188 | 8.00 | 5.50 | 2.467 | .014 |
| 7.00 | 6.00 | 7.00 | 6.00 | ||||||
| 88.12 | 98.59 | 103.78 | 84.32 | ||||||
| NRS | 4.00 (3.00) | 3.00 | 4.00 | 5.599 | <.001 | 4.00 | 3.00 | 3.259 | .001 |
| 3.00 | 3.00 | 2.00 | 2.25 | ||||||
| 69.24 | 113.34 | 106.81 | 81.33 | ||||||
| Anxiety of self‐care for a newborn during the day | 2.00 (4.00) | 2.00 | 2.00 | 1.528 | .127 | 3.00 | 1.00 | 5.002 | <.001 |
| 3.25 | 4.00 | 4.00 | 3.00 | ||||||
| 87.27 | 99.26 | 113.58 | 74.63 | ||||||
| Anxiety of self‐care for a newborn at night | 3.00 (4.00) | 2.00 | 3.00 | 1.091 | .275 | 4.00 | 1.00 | 4.595 | <.001 |
| 5.00 | 4.00 | 4.00 | 4.00 | ||||||
| 89.16 | 97.78 | 112.09 | 76.10 | ||||||
| Anxiety of newborn crying | 2.00 (4.00) | 2.00 | 2.00 | 1.265 | .206 | 4.00 | 2.00 | 4.399 | <.001 |
| 5.00 | 4.50 | 5.00 | 3.00 | ||||||
| 88.39 | 98.38 | 111.33 | 76.86 | ||||||
| Anxiety of getting COVID‐19 | 3.00 (6.00) | 2.00 | 3.00 | 1.081 | .280 | 2.00 | 4.00 | 0.809 | .419 |
| 4.00 | 5.50 | 5.00 | 7.00 | ||||||
| 89.23 | 97.73 | 90.83 | 97.14 | ||||||
Abbreviations: AAQ‐2, Acceptance and Action Questionnaire‐2; HADS‐A, Hospital Anxiety and Depression Scale ‐ Anxiety; IQR, interquartile range; NRS, Numerical Rating Scale for pain; NRS‐A, Numerical Rating Scale for anxiety; STAI, State‐Trait Anxiety Inventory; U(Z), Mann‐Whitney U test.
Comparison of Patients at Low and High Risk of Developing Anxiety Disorders by PF, Pain, and Anxiety
Of 187 puerperal women, 79.7% (n=149) were at low risk of developing an anxiety disorder and 20.3% (n=38) were at high risk of developing an anxiety disorder based on scores on the HADS‐A. The Mann‐Whitney U test showed that patients at high risk of developing an anxiety disorder had significantly higher levels of pain (P < .01) and anxiety as a state and trait (P < .001) than patients at low risk. High‐risk patients also had a higher level of anxiety of self‐care for a newborn during the day and at night and of the newborn crying than low‐risk patients (P < .001). There was no statistically significant difference between the groups in the level of anxiety of getting COVID‐19 (P > .05). Patients at a higher risk of developing an anxiety disorder had a lower PF level (P < .0001) than patients at lower risk of developing an anxiety disorder (Table 3).
Table 3.
Comparison of Psychological Flexibility, Anxiety, and Pain Between Women at Low and High Risk of Developing an Anxiety Disorder (N = 187)
| Women at Low Risk (n = 149) | Women at High Risk (n = 38) | |||||
|---|---|---|---|---|---|---|
| Questionnaire | Median | Mean Rank | Median | Mean Rank | U(Z) | P Value |
| AAQ‐2 | 15.00 | 86.91 | 19.50 | 121.79 | 3.550 | <.0001 |
| STAI‐T | 36.00 | 86.77 | 41.50 | 122.36 | 3.622 | <.0001 |
| STAI‐S | 40.00 | 80.21 | 58.00 | 148.07 | 6.902 | <.0001 |
| NRS‐A | 3.00 | 79.56 | 7.00 | 150.61 | 7.276 | <.0001 |
| HADS‐A | 5.00 | 75.00 | 12.5 | 168.50 | 9.537 | <.0001 |
| Anxiety of self‐care for a newborn during the day | 1.00 | 82.16 | 5.00 | 138.63 | 5.789 | <.0001 |
| Anxiety of self‐care for a newborn at night | 2.00 | 82.16 | 6.00 | 140.43 | 5.988 | <.0001 |
| Anxiety of newborn crying | 2.00 | 83.23 | 6.00 | 136.22 | 5.443 | <.0001 |
| Anxiety of getting COVID‐19 | 2.00 | 92.16 | 4.00 | 101.20 | 0.932 | .352 |
| NRS | 3.00 | 88.09 | 4.00 | 117.17 | 2.994 | .003 |
Abbreviations: AAQ‐2, Acceptance and Action Questionnaire‐2; HADS‐A, Hospital Anxiety and Depression Scale‐Anxiety; NRS, Numerical Rating Scale for pain; NRS‐A, Numerical Rating Scale for anxiety; STAI, State‐Trait Anxiety Inventory; U(Z), Mann‐Whitney U test.
Relationship Between Anxiety and PF
The first step in investigating the relationship between anxiety and PF was to measure the bivariate correlations between the AAQ‐2 score and the different measures of state anxiety. As a comparison, correlations were also measured between a degree of patient's flexibility and other measures, such as pain and trait anxiety. Statistically significant positive relationships were found between all examined anxieties and PI, pain, and trait anxiety. The higher the PF patients demonstrated, the less anxiety and pain they had. The strongest positive relationship was noted for PI and trait anxiety (ρ = 0.659; P < .001), whereas the weakest was for PI and pain (ρ = 0.168; P < .05). The correlations are depicted in Table 4.
Table 4.
Correlations Among Scores of AAQ‐2, NRS, and Anxiety Scales in Women in the Rooming‐in Unit (N = 187)
| Questionnaire | AAQ‐ 2 | P Value | NRS | P Value | STAI‐ T | P Value |
|---|---|---|---|---|---|---|
| HADS‐A | 0.443 | <.001 | 0.351 | <.001 | 0.448 | <.001 |
| STAI‐T | 0.659 | <.001 | 0.156 | .033 | 1.000 | ‐ |
| AAQ‐2 | 1.000 | ‐ | 0.168 | .022 | 0.659 | <.001 |
| STAI‐S | 0.274 | <.001 | 0.359 | <.001 | 0.419 | <.001 |
| NRS‐A | 0.312 | <.001 | 0.545 | <.001 | 0.367 | <.001 |
| NRS | 0.168 | .022 | 1.000 | ‐ | 0.156 | .033 |
| Anxiety of self‐care for a newborn during the day | 0.233 | .001 | 0.491 | <.001 | 0.315 | <.001 |
| Anxiety of self‐care for a newborn at night | 0.287 | <.001 | 0.479 | <.001 | 0.329 | <.001 |
| Anxiety of newborn crying | 0.317 | <.001 | 0.404 | <.001 | 0.340 | <.001 |
| Anxiety of getting COVID‐19 | 0.206 | .005 | 0.296 | <.001 | 0.181 | .013 |
Abbreviations: AAQ‐2, Acceptance and Action Questionnaire‐2; HADS‐A, Hospital Anxiety and Depression Scale‐Anxiety; NRS, Numerical Rating Scale for pain; NRS‐A, Numerical Rating Scale for anxiety; STAI, State‐Trait Anxiety Inventory.
Anxiety Disorder Risk Prediction
The next step of the analysis was to calculate the anxiety disorder risk prediction using single explanatory variables, such as PF, anxiety (measured with questionnaires other than HADS‐A), and pain (Table 5). One‐way logistic regression showed that the anxiety disorder can be predicted by NRS‐A (R2 , 46.7%) or STAI‐S (R2 , 44.9%) among considered scales. Both NRS‐A (odds ratio [OR], 1.957; 95% CI, 1.588‐2.411) and STAI‐S (OR, 1.149; 95% CI, 1.098‐1.203) were significant predictors. Trait anxiety explained a similar percentage of variance (R2 , 13.8%; OR, 1.113; 95% CI, 1.053‐1.176) to PI (R2 , 13.1%; OR, 1.103; 95% CI, 1.049‐1.160).
Table 5.
One‐Way Logistic Regression Analysis to Predict Anxiety Disorder Risk (N = 187)
| Questionnaire | B (SE) | R2 | Wald Statistic | P Value | OR (95% CI) |
|---|---|---|---|---|---|
| STAI‐T | 0.107 (0.028) | 0.138 | 14.591 | <.0001 | 1.113 (1.053‐1.176) |
| AAQ‐2 | 0.098 (0.026) | 0.131 | 14.497 | <.0001 | 1.103 (1.049‐1.160) |
| STAI‐S | 0.139 (0.023) | 0.449 | 36.195 | <.0001 | 1.149 (1.098‐1.203) |
| NRS‐A | 0.671 (0.106) | 0.467 | 39.806 | <.0001 | 1.957 (1.588‐2.411) |
| NRS | 0.222 (0.093) | 0.048 | 5.617 | .018 | 1.248 (1.039‐1.499) |
| Anxiety of self‐care for a newborn during the day | 0.437 (0.080) | 0.290 | 29.547 | <.0001 | 1.548 (1.323‐1.813) |
| Anxiety of self‐care for a newborn during at night | 0.357(0.065) | 0.275 | 29.808 | <.0001 | 1.429 (1.257‐1.625) |
| Anxiety of newborn crying | 0.347 (0.066) | 0.255 | 27.957 | <.0001 | 1.415 (1.244‐1.610) |
| Anxiety of getting COVID‐19 | 0.041 (0.052) | 0.005 | 0.614 | .433 | 1.042 (0.941‐1.153) |
Abbreviations: AAQ‐2, Acceptance and Action Questionnaire‐2; B(SE), beta(standard error); HADS‐A, Hospital Anxiety and Depression Scale‐Anxiety; NRS, Numerical Rating Scale for pain; NRS‐A, Numerical Rating Scale for Anxiety; OR, odds ratio; STAI, State‐Trait Anxiety Inventory.
ROC analysis found that AAQ‐2 and STAI‐T were sufficeint predictors of a high risk for developing anxiety disorder. The model parameters for AAQ‐2 were area under the curve (AUC) = 0.687; P < .001; sensitivity = 0.816; and specificity = 0.490; for STAI‐S they were AUC = 0.690; P < .001, sensitivity = 0.605, and specificity = 0.718 (Figure 1). The analysis suggested a value of 14.50/49 on the AAQ‐2 scale and the value of 39.50/80 on the STAI‐T as thresholds to indicate the risk of an anxiety disorder (defined by the HADS‐A reference cutoff of 10).
Figure 1.
Receiver Operator Curves for AAQ‐2 and STAI‐T Predicting Anxiety
Calculated for the Acceptance and Action Questionnaire‐2 (AAQ‐2) (area under the curve [AUC] = 0.687; P < .001) and for the State‐Trait Anxiety Inventory, anxiety as a trait (STAI‐T) (AUC = 0.690; P < .001) using the Hospital Anxiety and Depression Scale‐Anxiety, in which a score of >10 was selected as an indicator of anxiety disorders. An AAQ‐2 cutoff value of 14.50/49 reflected the best combination of sensitivity (82%) and specificity (49%). An STAI‐T cutoff value of 39.50/80 reflected the best combination of sensitivity (60%) and specificity (72%).
DISCUSSION
Our study showed that on the second postpartum day, patients after CB showed significantly greater anxiety on the NRS‐A scale and pain than patients after VB, and primiparous women had significantly higher levels of most anxieties and pain than multiparous women. Patients at high risk of developing an anxiety disorder additionally had a lower level of PF than patients at low risk of developing an anxiety disorder. PF was shown to be negatively correlated with anxiety and pain in women after childbirth.
Patients of our study after CB had higher levels of pain (P < .001) and anxiety as a state (P < .05) on NRS‐A than patients after VB. The groups did not differ in terms of anxiety measured by the STAI and HADS‐A questionnaires. However, as shown by Klages et al, significant correlations occur between anxiety (STAI‐S and STAI‐T) and pain in women undergoing amniocentesis and chorionic villus biopsy. 49 We revealed that the NRS‐A correlates with the perceived pain (ρ = 0.545, P < .001). Labaste et al validated the use of NRS‐A in patients after surgery and concluded that this simple tool is useful for detecting the postoperative pain component. 50 We did not identify any recent studies comparing pain and anxiety on the second postpartum day (48 hours) in patients after CB versus VB. The obtained knowledge may, however, complement the study by Lai et al 51 showing that patients in a rooming‐in ward (48‐72 hours) after CB versus VB had a significantly higher level of fatigue (P < .01). Other studies showed that even at the end of the postpartum period, patients after CB had a considerably worse physical health condition, including greater pain, than patients after VB. 52 , 53 , 54
According to our findings, the levels of pain and anxiety on the STAI‐S, NRS‐A, HADS‐A, and the anxiety of self‐care for a newborn and newborn crying scales were higher in primiparous women than in multiparous women. This is in line with other studies that show that being a mother for the first time is associated with enormous stress and perceived anxiety. 55 , 56 , 57 Copeland and Harbaugh 55 emphasized they wanted to describe a phenomenon that is not related to psychopathology but is a normal transition state experienced by most women after giving birth to their first child. The study by Hung 58 showed that primiparous and multiparous women did not differ in terms of mental health. In contrast, primiparous women experienced greater postpartum stress related to their new role as a mother. Similarly, in our study, the participants were healthy women, after giving birth to a healthy newborn, with no psychiatric history. However, giving birth to the first child increased anxiety as a state related to motherhood, which was not observed in multiparous women. The primiparous women also had a higher level of anxiety on the HADS‐A scale compared with multiparous women. However, the median value of anxiety in this group was 8, which is below the cutoff point for a high risk of anxiety disorders (value of 10).
On the other hand, 20.3% of our study sample were at high risk of developing anxiety disorders, with a level of anxiety of above 10 on the HAD‐A. A similar result was obtained in another study conducted several years before the pandemic, in which the incidence of perinatal anxiety was estimated at approximately 22%. 20 Studies conducted among pregnant women during the pandemic showed the prevalence of anxiety of approximately 17%. 59 , 60 The comparison of patients at low and high risk of developing an anxiety disorder in our study revealed that these groups differed not only in the levels of most anxieties but also in the levels of PF and pain. Differences related to specific motherhood anxieties were significant, whereas the difference related to the anxiety of getting COVID‐19 was not significant. Perhaps the risk of an anxiety disorder in the puerperium is linked primarily to the specific perinatal situation of mothers. The COVID‐19 pandemic was a stress factor for populations in various countries. 30 , 61 , 62 In Poland, at that time, women with their newborns constituted a homogeneous group with respect to fear of acquiring COVID‐19. 63 , 64
We also observed that women at high risk of developing an anxiety disorder had higher levels of other anxieties, including the anxiety of a newborn crying, than patients at low risk. Anxiety and frustration in women after childbirth may be related to the fact that they cannot determine why their newborns are crying and to the lack of the ability to calm the newborn, and this, in turn, may disrupt the early bond between the woman and her newborn. 51 Additionally in our study, primiparous women versus multiparous women and patients at high risk of developing an anxiety disorder versus those at low risk presented with a higher level of anxiety of self‐care for their newborn. Women after childbirth from the study of Consales et al 65 described a night alone with a newborn in a hospital room as the worst rooming‐in experience.
The levels of dispositional trait anxiety and PF did not differ by birth mode and parity, but they did in terms of a risk of developing an anxiety disorder. Reports from the literature consistently show the relationship between high anxiety as a trait and the risk of developing an anxiety disorder in adults. 66 , 67 This result is also in line with studies that present PF as a factor strongly associated with mental health. 30 , 45 , 68 AAQ‐2 correlated with trait anxiety (STAI‐T) and hospital anxiety (HADS‐A) with similar strength. Additionally, AAQ‐2 and trait anxiety (STAI‐T) very similarly explain the risk of anxiety disorder in women postpartum, 46 which is due to a strong positive correlation between PF 45 and trait anxiety (ρ = 0.659; P < .001). The above result of our study is similar, although slightly lower, than in the study on the Polish general population (r = 0.78; P < .001). 46 It is also similar to the correlation between the AAQ‐2 and General Anxiety Disorder questionnaire scores as a measure of generalized anxiety (ρ = 0.66; P < .001) in the study reporting that PF can be a measure of mental resilience in the context of COVID‐19. 69
The strength of the relationship between AAQ‐2 and HADS‐A (ρ = 0.443; P < .001) in our study was weaker than the strength of the relationship between AAQ‐2 and HADS‐A (ρ = 0.643; P < .001) in a study in which half of the studied people had cancer. 70 That study reported a significantly lower mean level of PF (AAQ‐2) in patients without cancer than in patients with cancer (14.17 vs 20.63, respectively). In our study, a similar difference was shown between patients at low risk of developing anxiety disorder and those at high risk of developing anxiety disorder (median, 15.00 vs 19.50, respectively).
In addition, PI was positively related to all anxieties and to the pain of postpartum women staying in our rooming‐in unit during the pandemic. Our study is the first to show an association of PI with acute pain in the puerperium. This relationship is significant, although the correlation is weak (ρ = 0.168; P < .05). So far, PF exhibited a protective role in people with chronic pain. 31 , 34 , 71 For example, in the study of Yu et al, 31 the correlation between PF, measured with a tool other than AAQ‐2, and the intensity of chronic pain was significant (r = −0.24; P < .001), whereas the correlation between PF and anxiety of COVID‐19 had a similar strength (r = 0.15‐0.30; P < .001) as in our study (ρ = 0.21; P < .001).
Our study was the first to show that low PF (PI) measured by AAQ‐2 may have a predictive value for the risk of anxiety disorders during the puerperium. To the best of our knowledge, there are no studies to date that analyze the AAQ‐2 cutoff point for women in the puerperium. The cutoff point of the AAQ‐2 score could be used as a reference to the initial identification of outcomes associated with a significant experience avoidance index that influences the risk of anxiety disorders among patients after birth. However, because of the low specificity values in the ROC analysis and the small number of women being at high risk of developing an anxiety disorder, the cutoff point of 14.50 on AAQ‐2 should be treated as a preliminary result that requires verification in a larger population. The obtained results encourage further research on the mindful acceptance of anxiety in the puerperium. Designing preventive and intervention measures aimed at increasing PF may improve the mental condition of women after childbirth.
Several limitations of our study have to be mentioned. First, we used a single diagnostic tool to measure PF. This was because women in the puerperium are tired and burdened with caring for the newborn. It was difficult for them to complete several questionnaires at the same time. Thus, we chose a representative tool to measure the avoidance of difficult emotions. 45 AAQ‐2 has been recognized for its high internal consistency and reliability in various types of psychopathological diseases and is widely used in various target groups. 72 , 73 , 74 , 75 , 76 The second limitation is the single‐center design. On the other hand, the strength of the study lies in investigating anxiety in healthy women who gave birth to healthy newborns during the COVID‐19 pandemic and who stayed in the rooming‐in unit during their puerperium. All patients were in the same situation regarding self‐care for the newborn, without the support of their relatives. Despite those limitation, the results of the present research can be generalized to countries with a similar culture and a similar organization of maternity units operating in the rooming‐in system. The results encourage further research on anxiety and its relationship with PF in the puerperium in other clinical centers and in the populations of women who gave birth to newborns requiring specialized treatment. This particularly applies to situations in which a woman does not have support from relatives.
CONCLUSION
PF is an important psychological construct related to the mental and physical condition of women after childbirth. Thus, increasing PF in women after childbirth may be considered as an important goal of preventive and intervention measures. The staff of obstetric wards operating in the rooming‐in system should routinely monitor the mental condition of women after childbirth, in addition to pain, and provide additional support to women who are first‐time mothers.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
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