What is pregnancy-related anxiety and how can I identify someone experiencing it?

Pregnancy is a life-changing event which is accompanied by rapid physical and psychological changes and adjustments (Soma-Pillay et al., 2016). For some individuals, navigating this significant developmental period may be fraught with anxiety and concern (Viswasam et al., 2019).

Pregnancy-related anxiety is a distinct type of anxiety characterised by pregnancy-specific concerns and may affect at least 1 in 10 pregnant people (Brunton et al., 2019; Koelewijn et al., 2017). These individuals have elevated fears or worries about their unborn child, impending childbirth, or interactions with medical staff.

Anxiety is a diffuse emotion that relates to underlying fears and worries that may be general or specific in nature (Austin et al., 2007; Rachman & Rachman, 2019). Around 17% of the general population will experience an anxiety disorder in their lifetime (Australian Bureau of Statistics, 2022).

However, pregnancy-related anxiety is a distinct type of anxiety that is experienced during pregnancy (Brunton et al., 2018; Robertson-Blackmore et al., 2016). It is characterised by pregnancy-specific concerns, including the course of pregnancy, childbirth, wellbeing, healthcare, family life, and parenthood (Brunton et al., 2019).* While the content and breadth of these worries may vary individually or cross-culturally, core areas of concern that are consistently identified include childbirth, baby health, body image, and interactions with medical staff (Brunton et al., 2021; Dryer et al., 2022). While the prevalence of pregnancy-related anxiety is challenging to determine, international prevalence estimates vary from 11% to 56% (Koelewijn et al., 2017; Nath et al., 2019).

Pregnancy-related anxiety can have significant negative consequences for the health of the parent and their child including increased risk of preterm birth, developmental delays, and postnatal depression (Dunkel Schetter et al., 2021; Garcia et al., 2021; Robertson-Blackmore et al., 2016). Some evidence suggests pregnancy-related anxiety is a ‘potent and often more consistent predictor’ of adverse outcomes in late pregnancy and childbirth than generalised anxiety (Dunkel Schetter et al., 2022; Kane et al., 2014, p. 13).

*This article will focus only on pregnancy; however, trying to conceive can also be a significant period of stress and anxiety (Sweeny et al., 2015), particularly for those with fertitlity challenges and LGBQTIA+ people (Topper & Bauermeister, 2022). Postnatal mental health challenges are also prominent, particularly following a pregnancy loss (Nynas et al., 2015).

Until recently, pregancy-related anxiety has not been widely recognised in clinical settings (Dunkel Schetter & Ponting, 2021). Australian guidelines acknowledge that anxiety during pregnancy is common and advocate using general anxiety measures, psychosocial assessment, and clinical judgment for screening and assessment (Department of Health and Aged Care, 2020). The guidelines outline that this practice should be routine for most public maternity units. Private sector clinics may assess psychosocial risk and mental health; however, formal screening procedures have not been widely adopted (Kohlhoff et al., 2016).

Conventional measures of general anxiety may lead to under-diagnosis of pregnancy-related anxiety as they are non-specific to the underlying concerns of pregnancy. These measures may also be associated with misdiagnosis as they contain items that overlap with pregnancy experiences (e.g. racing heart; Brunton et al., 2015).

Specific psychological scales to screen for the presence of pregnancy-related anxiety have recently been developed, such as the Pregnancy-related Anxiety Scale (PrAS; Brunton et al., 2018; 2019) and the Pregnancy-related Anxiety Screener Scale (PrAS-S; Dryer, et al., 2022). However, the effectiveness and usefulness of these measures in antenatal care is still being investigated. Moreover, specific guidelines for screening specifically for pregnancy-related anxiety are still emerging. As such, tools developed specifically for pregnancy-related anxiety are not yet formally recognised in many of these guidelines (Kohlhoff, 2022).

In the absence of guidelines, other indicators can help to identify those at risk of pregnancy-related anxiety. For example, risk factors include:

• a history of childhood abuse
• being pregnant for the first time
• low self-efficacy
• older age
• lower socioeconomic status
• low social support; and
• being a migrant (Brunton et al., 2020a; 2020b; Nath et al., 2019; Sharapova & Ratcliff, 2021).

Current or previous anxiety and major life stressors are also identified predictors of pregnancy-related anxiety (Mudra et al., 2020). Feelings of isolation and previous or current experiences of family violence are also likely associated with this anxiety, given their links to general anxiety experienced during pregnancy (Austin et al., 2017). However, evidence for this connection is still emerging.

Interventions for pregnancy-related anxiety are in their infancy. However, emerging evidence suggests that specific psychological intervention frameworks that allow for pregnancy-specific concerns to be addressed hold promise (Leigh & Brunton, 2021). For example, the results of initial trials of cognitive behavioral therapy (CBT) and mindfulness coupled with psychoeducation**, indicate that these interventions may reduce levels of pregnancy-specific fears and worries (Green et al., 2020; Guardino et al., 2014). Indeed psychoeducation is considered an essential aspect of these therapies as it can target specific areas of pregnancy-related concern (Leigh & Brunton, 2021).

Table 1 provides information on support services and resources for individuals experiencing pregnancy-related anxiety and their families. Refer to Further reading and related resources for more information for professionals.

Table 1:  Support services for pregnancy-related anxiety

**’Psychoeducation’ refers to the provision of education and information to those experiencing distress.

The following tips may help practitioners working in antenatal care to identify, assess and support individuals with pregnancy-related anxiety:

• Consider the social determinants of pregnancy-related anxiety. Many risk factors relate to low resources and support (e.g. socioeconomic resources, social support) and previous adverse experiences. Onwards referral may be important to connect families with other services and supports.
• Use assessment scales that are sensitive or specific to pregnancy-related anxiety, where available. For example, the Pregnancy-related Anxiety Scale (PrAS) and the Pregnancy-related Anxiety Screener Scale (PrAS-S).
• Practice active listening and ask parents about their feelings about pregnancy and parenting. Many pregnant people, especially those from minority or disadvantaged backgrounds may have had their concerns invalidated or dismissed, which can make anxiety worse.
• Take a trauma-informed and inclusive approach. A history of abuse and low social support are risk factors for pregnancy-related anxiety. Gender-sensitive and culturally appropriate care is critical to ensure all parents receive adequate and appropriate support.

Individuals experiencing pregnancy-related anxiety are not commonly identified, assessed or supported. Increasing awareness of pregnancy-related anxiety, and ensuring parents are routinely and accurately identified and supported is critical to ensuring optimal antenatal care.

Specific pregnancy-related anxiety assessment tools are currently being developed and validated, as existing measures of general anxiety may result in under diagnosis. This article has also outlined implications for practitioners to better identify, assess and support families.

Pregnancy-related anxiety: Theory, research and practice (Dryer, R., & Brunton, R., [Eds.])

This book is an ideal resource for academics, but is also suitable for professionals and higher education students who want to understand pregnancy-related anxiety, its antecedents, consequences and the wider implications for assessment and treatment. The book provides an overview of the key issues and debates around pregnancy-related anxiety from leading researchers and clinicians in the field.

Understanding pregnancy anxiety: Concepts, correlates, and consequences (Guardino, C. M., & Dunkel Schetter, C., Zero to Three)

This article is targeted at professionals working in the area of prenatal and early childhood development. It describes and defines pregnancy-related anxiety and summarises research evidence of associated adverse outcomes. The article considers characteristics that may contribute to high levels of pregnancy-related anxiety, potential clinical implications and interventions.

Women’s psychosocial health with Dr Robyn Brunton podcast (Psych Attack)

In this episode of the Psych Attack podcast, Dr Robyn Brunton talks about her career and what led her to study pregnancy-related anxiety.

Perinatal care for people who have experienced sexual trauma podcast (Emerging Minds)

In this podcast episode, Vicki Mansfield (Emerging Minds) discusses the importance of trauma-informed pregnancy and postnatal care for people who’ve experienced sexual trauma.

Perinatal support strategies for Aboriginal and Torres Strait Islander parents webinar (Child Family Community Australia & Emerging Minds)

This webinar, co-produced by CFCA and Emerging Minds, explores insights for practice strategies when working with Aboriginal and Torres Strait Islander families in the perinatal period.

Healing the Past by Nurturing the Future resources

Healing the Past by Nurturing the Future is a co-design project that aims to develop safe and appropriate strategies for addressing trauma in the perinatal period. The project has produced information on how to implement a trauma-informed and culturally safe approach to perinatal care. See also their review of evidence on parenting after childhood maltreatment.

References

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Austin, M-P., Tully, L., & Parker, G. (2007). Examining the relationship between antenatal anxiety and postnatal depression. Journal of Affective Disorders, 101, 169–174. doi:  10.1016/j.jad.2006.11.015

Austin, M-P., Highet, N., and the Expert Working Group. (2017). Mental health care in the perinatal period: Australian clinical practice guideline. Melbourne, VIC: Centre of Perinatal Excellence.

Brunton, R., Gosper, K., & Dryer, R. (2021). Psychometric evaluation of the pregnancy-related anxiety scale: acceptance of pregnancy, avoidance, and worry about self subscales. Journal of Affective Disorders, 278, 341–349. doi: 10.1016/j.jad.2020.09.064

Brunton, R., Simpson, N., & Dryer, R. (2020a). Pregnancy-related anxiety, perceived parental self-efficacy and the influence of parity and age. International Journal of Environmental Research & Public Health, 17(18). doi: 10.3390/ijerph17186709

Brunton, R., Wood, T., & Dryer, R. (2020b). Childhood abuse, pregnancy-related anxiety and the mediating role of resilience and social support. Journal of Health Psychology, 1359105320968140. doi: 10.1177/1359105320968140

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