by Marcela Muricy, November 9, 2021
Pregnancy is an adventurous time— a time of changes in the body that can be welcoming or scary, peaceful or torment, the feeling of finally having everything put together or the stress of slamming your finger between the car door. Any way you twist it, it is a very complicated and unique time for every pregnant person. Most people will fear the aftermath, the risk of experiencing Postpartum Depression, the more intense version of the “baby blues”. Yet, what many pregnant people, their families, and even physicians and researchers overlook, however, is another mental health change that may impact them — and their baby — during the pregnancy itself: antenatal anxiety. “Antenatal”, or “pre-birth”, represents the time period before someone gives birth, therefore encapsulating the symptoms they may begin to encounter, such as mild to intense anxiety. Experienced by about 10% of pregnant people (Falah-Hassani et al., 2017), antenatal anxiety consists of obsessive and excessive worry that begins to impact their daily function, including concerns of maternal/fetal wellbeing, illness in the partner, and the possibility of maternal mortality (Johns Hopkins). These feelings, when experienced chronically and not treated properly, can have lifelong impacts on the child’s development (Misri et al., 2015). It is crucial to consider the prevalence of antenatal anxiety, how much it flies under the radar, and how harmful it is to mothers and their children, particularly during a pandemic in which treatment is very limited.
According to various studies, high antenatal anxiety can cause a decrease in the child’s head circumference, Apgar scores, and body length, as well as an increase in preterm birth rates, maternal eating disorders— and even cognitive and anger issues that can follow the child into adolescence and adulthood (Sarkar et al., 2017; Grigoriadis et al., 2018). For the pregnant person, antenatal anxiety can be a key predictor of postpartum depression (which is experienced by about 15% of pregnant people), so that high levels of antenatal anxiety are strongly correlated with higher likelihood of postpartum depression (Yim and Schetter, 2019; Slomian et al., 2019). Antenatal anxiety, then, although harder to identify, is also crucial in its correlation to PPD, and can help in the prevention of not only antenatal symptoms, but the gruesome symptoms that may follow the long road of PPD.
The main risk factors for developing maternal anxiety have proven to be high maternal preterm BMI, as well as a history of depression and mental issues (Holton et al., 2019; Dachew et al., 2021). Pregnancy ultimately causes a change in social state, hormonal imbalances, and lack of social support, all of which can serve to strain the pregnant person’s mental state and exacerbate past health issues. The listed risk factors, on top of the typical strains of pregnancy, leaves them very vulnerable to developing antenatal anxiety, making regular screenings and checkups even more crucial to preventing these symptoms as early as possible.
The current primary method of prevention includes frequent screenings, however it is proven that there is a strong correlation between pregnant people experiencing antenatal anxiety and choosing to attend less screenings/checkups, and so they are likely to be overlooked. It has been shown that therapy and social support groups tailored to them aids in decreasing antenatal anxiety in vulnerable populations, as well as populations not considered at risk for anxiety, both of which experienced an increase in overall quality of life (Li et al., 2020). The major causes of antenatal anxiety, then, are well treated and relieved by an increase in social interactions and support.
This explains the increase in antenatal anxiety since March 2020; the COVID-19 pandemic has limited the availability of antenatal anxiety prevention and birthed a unique population of vulnerable mothers. Throughout the pandemic, there was a reported decrease in maternal mental health, and an increase in anxiety, depression, and OCD as a result of the fear of infection and social isolation (Hessami et al., 2020; Hinds et al., 2021). This was especially true for mother’s of high risk pregnancies (for instance, being at risk of preterm labor or a diabetic mother at risk of Diabetic Ketoacidosis) and with lower levels of education (Sinaci 2020). Within this sample set, there has also been an increase in PTSD symptoms because of the high stress level associated with the pandemic and the lack of social support (Hocaoglu et al., 2020). The prevention for this population was only possible within the home (self-prevention methods), or with a specialist over a digital platform— both of which are difficult to maintain and ineffective compared to in-person treatment and support (Akgor et al., 2021). This is also a possible challenge for pregnant people in poorer communities that cannot afford to attend regular checkups and screenings, which is particularly risky considering that, in worse financial conditions, they are significantly more likely to experience antenatal anxiety (Bayrampour et al., 2018; Dennis et al., 2018). The COVID-19 pandemic has exacerbated the impact of certain risk factors and exposed a disproportionate lack of resources available in impoverished communities, especially in times of need.
Antenatal anxiety, then, should be at the forefront of our conversation around the support pregnant people need during pregnancy. Not only should they undergo physical screenings and pelvic exams (as is customary), but they should receive just as many (if not more) regular check-ups regarding their mental health (Kitchen and Jack 2021; Li et al., 2020). Moreover, this check-up should not only be geared towards the most serious aspects of mental health (such as suicidal thoughts), but also towards the more subtle concerns that can accumulate and negatively impact their health over time. Antenatal anxiety and its symptoms may be experienced independently of anything else, making it more difficult to distinguish between normal and abnormal symptoms (Misri et al., 2015). Persistent screenings, intensive education about these possibilities/distinctions, and further treatment studies are crucial to combatting the high prevalence of antenatal anxiety. This is especially true with vulnerable populations that have previous mental or physical health issues, or have limited access to resources due to their financial situation. Pregnant people should know they are well-supported, and their families should know how best to support them— so that none of them may suffer alone.
1 An Apgar score is a postnatal test performed immediately after birth to evaluate the baby’s health. Each category (Appearance, Pulse, Grimace, Activity, and Respiration) gets its own Apgar score ranging from 0-2, 0 being the least healthy and 2 being the most (“What is the Apgar Score?”).
Akgor, U., Fadıloglu, E., Soyak, B., Unal, C., Cagan, M., Temiz, B. E., Erzenoglu, B.E., Ak, S., Gultekin, M., & Ozyuncu, O. (2021). Anxiety, depression and concerns of pregnant women during the COVID-19 pandemic. Archives of Gynecology and Obstetrics, 304(1), 125–130. https://doi-org.proxy.library.stonybrook.edu/10.1007/s00404-020-05944-1
Alipour, Z., Lamyian, M., & Hajizadeh, E. (2012). Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women. Women and Birth: Journal of the Australian College of Midwives, 25(3), e37–e43. https://doi.org/10.1016/j.wombi.2011.09.002
Bayrampour, H., Vinturache, A., Hetherington, E., Lorenzetti, D.L., & Tough, S. (2018). Risk factors for antenatal anxiety: A systematic review of the literature. Journal of Reproductive and Infant Psychology, 36(5), 476–503. https://doi-org.proxy.library.stonybrook.edu/10.1080/02646838.2018.1492097
Coelho, H.F., Murray, L., Royal-Lawson, M., & Cooper, P.J. (2011). Antenatal anxiety disorder as a predictor of postnatal depression: a longitudinal study. Journal of Affective Disorders, 129(1-3), 348–353. https://doi.org/10.1016/j.jad.2010.08.002
Dachew, B.A., Ayano, G., Betts, K., & Alati, R. (2021). The impact of pre-pregnancy BMI on maternal depressive and anxiety symptoms during pregnancy and the postpartum period: A systematic review and meta-analysis. Journal of Affective Disorders, 281, 321–330. https://doi-org.proxy.library.stonybrook.edu/10.1016/j.jad.2020.12.010
Dennis, C.L., Falah-Hassani, K., & Shiri, R. (2017). Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry: The Journal of Mental Science, 210(5), 315–323. https://doi.org/10.1192/bjp.bp.116.187179
Grigoriadis, S., Graves, L., Peer, M., Mamisashvili, L., Tomlinson, G., Vigod, S.N., Dennis, C.L., Steiner, M., Brown, C., Cheung, A., Dawson, H., Rector, N.A., Guenette, M., & Richter, M. (2018). Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: Systematic review and meta-analysis. The Journal of Clinical Psychiatry, 79(5), 17r12011. https://doi.org/10.4088/JCP.17r12011
Hessami, K., Romanelli, C., Chiurazzi, M., & Cozzolino, M. (2020). COVID-19 pandemic and maternal mental health: A systematic review and meta-analysis. The Journal of Maternal-fetal & Neonatal Medicine: The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 1–8. Advance online publication. https://doi-org.proxy.library.stonybrook.edu/10.1080/14767058.2020.1843155
Hinds, C., Lindow, S.W., Abdelrahman, M., Hehir, M P., & O’Connell, M.P. (2021). Assessment of antenatal anxiety, depression and obsessive-compulsive disorder in pregnant women in the COVID-19 era. Irish Journal of Psychological Medicine, 1–7. Advance online publication. https://doi.org/10.1017/ipm.2021.57
Hocaoglu, M., Ayaz, R., Gunay, T., Akin, E., Turgut, A., & Karateke, A. (2020). Anxiety and post-traumatic stress disorder symptoms in pregnant women during the COVID-19 pandemic’s delay phase. Psychiatria Danubina, 32(3-4), 521–526. https://doi.org/10.24869/psyd.2020.521
Holton, S., Fisher, J., Nguyen, H., Brown, W.J., & Tran, T. (2019). Pre-pregnancy body mass index and the risk of antenatal depression and anxiety. Women and Birth: Journal of the Australian College of Midwives, 32(6), e508–e514. https://doi-org.proxy.library.stonybrook.edu/10.1016/j.wombi.2019.01.007
Kitchen F.L. &, Jack B.W. Prenatal Screening. [Updated 2021 Jul 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470559/
Li, C., Sun, X., Li, Q., Sun, Q., Wu, B., & Duan, D. (2020). Role of psychotherapy on antenatal depression, anxiety, and maternal quality of life: A meta-analysis. Medicine, 99(27), e20947. https://doi-org.proxy.library.stonybrook.edu/10.1097/MD.0000000000020947
Misri, S., Abizadeh, J., Sanders, S., & Swift, E. (2015). Perinatal generalized anxiety disorder: Assessment and treatment. Journal of Women’s Health (2002), 24(9), 762–770. https://doi.org/10.1089/jwh.2014.5150
Sarkar, K., Das, G., Chowdhury, R., Shahbabu, B., Sarkar, I., Maiti, S., & Dasgupta, A. (2017). Screening antenatal anxiety: Predicting its effect on fetal growth. Journal of Family Medicine and Primary Care, 6(1), 131–135. https://doi.org/10.4103/2249-4863.214956
Sinaci, S., Ozden Tokalioglu, E., Ocal, D., Atalay, A., Yilmaz, G., Keskin, H. L., Erdinc, S. O., Sahin, D., & Moraloglu Tekin, O. (2020). Does having a high-risk pregnancy influence anxiety level during the COVID-19 pandemic?. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 255, 190–196. https://doi-org.proxy.library.stonybrook.edu/10.1016/j.ejogrb.2020.10.055
What is the Apgar score? Johns Hopkins All Children’s Hospital. (2021). Retrieved November 7, 2021, from https://www.hopkinsallchildrens.org/Patients-Families/Health-Library/HealthDocNew/What-Is-the-Apgar-Score#:~:text=The%20Apgar%20score%20is%20a,at%205%20minutes%20after%20birth.
Yim, I.S., & Dunkel Schetter, C. (2019). Biopsychosocial predictors of perinatal depressive symptoms: Moving toward an integrative approach. Biological Psychology, 147, 107720. https://doi.org/10.1016/j.biopsycho.2019.107720