Title: Methods of assessing perinatal anxiety (MAP): The acceptability, effectiveness and feasibility of different approaches
Funder: Department of Health and Social Care

Abstract: Mental illness affects one in five women during pregnancy and the first year after birth, costing UK society £8.1 billion for every year of births. Depression and anxiety are most common but there is very little research on anxiety. Perinatal anxiety affects around 15% of women and leads to greater risk of premature birth, postnatal depression and long-term mental health and behaviour problems in their children. It is currently recommended that women are asked two questions about anxiety by their midwife. However, it is not known if these are the best questions to identify women who need treatment. _x000D_ _x000D_ We aim to solve this by finding the best questionnaire to identify women with perinatal anxiety. This will help us treat women early - reducing the number of women who experience long term anxiety and improving health of women and their babies. To be useful the anxiety questionnaire must be: (1) acceptable to women; (2) effective at identifying women who require treatment and those who do not; (3) acceptable, practical and easy to use in the NHS and other UK health services._x000D_ _x000D_ We will address each of these important points through four connected projects. We will compare four different anxiety questionnaires in NHS services in England and Scotland. We selected the questionnaires by looking at reviews of all the available evidence, and conducting our own research._x000D_ _x000D_ Project 1 will identify what questionnaires are most acceptable to women. We will interview women who are pregnant or recently gave birth. We will find out their views and experiences of being asked about anxiety during and after pregnancy._x000D_ _x000D_ Project 2 will identify the most effective questionnaire to identify women who need treatment. It will also establish the best time in pregnancy to ask women about anxiety in order to prevent long term problems. Women will complete the questionnaires three times in pregnancy and once after birth together with other questions about their health. Longer interviews will be carried out with some women to compare interview responses with questionnaire scores for accuracy_x000D_ _x000D_ Project 3 will determine which questionnaire is acceptable and practical to use in health services by implementing the most effective and acceptable questionnaire in two NHS Trusts. We will do this by asking healthcare professionals about their experience of using the questionnaire in these services._x000D_ _x000D_ Project 4 will look at anxiety during pregnancy and after birth in two areas with higher rates of mental illness. We will use information from Project 2 to identify how many women in these areas are affected and need treatment, as well as what increases women’s risk of having anxiety._x000D_ _x000D_ We developed this research with women who have experience of perinatal mental illness, midwives and mental health professionals. They identified this as a priority problem and will work with us through the project to ensure it is relevant to women and the NHS. The research team includes midwives, obstetricians, health visitors, GPs, nurses and mental health professionals._x000D_ _x000D_ This research will identify an acceptable and effective questionnaire for pregnant women that is practical to use in UK health services. We will work with women and health professionals to develop guides for services on how to put screening into practice which should enable wide scale implementation of screening for perinatal anxiety. Two events will be run by the NCT and Maternal Mental Health Change Agents to raise awareness and encourage uptake by services.

Lay abstract: Background: Mental illness affects 1 in 5 women in pregnancy and after birth with a cost to society of £8.1 billion for every annual cohort of births. Anxiety is one of the most common mental illnesses, affecting around 15% of women, and is associated with increased risk of adverse outcomes for women and their children. Despite this, there is no validated method of screening or assessing anxiety to identify women who need treatment._x000D_ _x000D_ To be useful, any assessment tool for antenatal anxiety must meet a number of criteria. It must be: (1) acceptable to women; (2) effective at identifying women who require treatment; (3) acceptable and feasible to use in different context of the NHS and other services across the UK; (4) acceptable and easy to use by health professionals._x000D_ _x000D_ Aims: This study aims to identify the most effective, acceptable and feasible method for assessing anxiety in women during pregnancy and after birth._x000D_ _x000D_ Methods: This will be achieved through 4 work packages (WP) that compare 4 different tools for assessing anxiety: 2 anxiety-specific measures and 2 mental health measures (GAD, SAAS, CORE-10, Whooley questions) selected on the basis of research and clinical evidence that suggest they may be effective. To ensure relevance to different UK health services the project will be conducted in NHS services in England and Scotland._x000D_ _x000D_ WP1 will identify which assessment tools are acceptable to women using a purposive sample of 40 pregnant and postpartum women. Cognitive interviews and in-depth qualitative interviews will be used to determine which assessment measures are most acceptable, and obtain women’s views and experiences of perinatal anxiety and mental health assessment._x000D_ _x000D_ WP2 will identify which assessment tool best identifies women who need treatment, as well as the optimal time to assess women during pregnancy. A systematic sample of 1915 women will be recruited in pregnancy and complete assessment tools at 12 weeks, 22 weeks and 31 weeks gestation and 6 weeks postpartum. Effectiveness of measures will be examined in terms of identifying women with poor daily functioning, quality of life, or those who need treatment. Potential confounding factors such as psychological treatment will be controlled for. Diagnostic accuracy will be established using gold standard clinical interviews on a randomly selected subsample of 401 women who score positive or negative for perinatal anxiety._x000D_ _x000D_ WP3 will determine which assessment tool is acceptable and feasible to use in health services by implementing anxiety assessment in 2 services and evaluating the acceptability and feasibility of use in these services. A theoretically-informed implementation guide will be developed, with targeted versions for maternity, psychological and primary care services to enable wide scale implementation of assessment of perinatal anxiety._x000D_ _x000D_ WP4 is a study within a project which will examine anxiety during pregnancy and after birth in two regions with a high prevalence of mental health conditions in the general population. This will use data from WP2 to determine the prevalence of perinatal anxiety, key sociodemographic risk factors and need for treatment in these regions._x000D_ _x000D_ Anticipated impact: This research will identify and implement evidence-based assessment of perinatal anxiety in health services, which is acceptable to women and health professionals. This will help identify women early, which will increase the chances for early intervention to improve maternal and child outcomes._x000D_ _x000D_ This research was developed through our partnerships with women who have experience of perinatal mental illness, health professionals and service managers. They have identified this as a priority problem and will work with us through the project to ensure its relevance to women and families and the NHS

Research activity codes: 4.3 INFLUENCES AND IMPACT
Health categories: MENTAL HEALTH;REPRODUCTIVE HEALTH AND CHILDBIRTH