Pregnancy specific anxiety: an under‐recognized problem
Authors: Prabha S. Chandra, Madhuri H. Nanjundaswamy
Journal: World Psychiatry (2020)

Howard and Khalifeh1 discuss the high prevalence of common mental disorders in the perinatal period and emphasize the need for early detection. Overall, research in this area has mostly focused on perinatal depression, and the role of anxiety has been relatively neglected until recently. It is also true, however, that anxiety and depression often co-exist. A recent systematic review reports the prevalence of any clinically diagnosed anx-iety disorder across the three trimesters of pregnancy to be 15.2%. In the first four weeks following childbirth, 17.8% of women experience significant anxiety symptoms. These rates are higher in low- and middle-income countries (LMICs) compared to high-income ones2. A form of anxiety which has not received the attention it deserves is pregnancy specific anxiety (PSA), i.e. the condition marked by worries, concerns and fears about pregnancy, childbirth, the health of the infant, and future parenting. This is considered to be distinct from generalized anxiety, as it occurs specifically during pregnancy and the anxiety revolves only around pregnancy-specific issues. PSA shows a different longitudinal course from generalized anxiety, is predictive of birth weight and gestational age at birth, and is more common in nulliparous women. An overlapping construct is that of pregnancy related anxiety (PRA), which was pro-posed following a concept analysis of 38 studies3. PRA is described as the nervousness and fear about the baby's health, the mother's health and appearance, the experience with the health care system, and social and financial issues in the context of pregnancy, childbirth and parenting. While the prevalence of PSA is reported to be around 29% in high-income countries4, studies from LMICs such as India, Iran, Tanzania and China have reported rates up to 55.7%. Most studies report higher rates of PSA in the third trimester of pregnancy5, 6. The interest in PSA has led to the development of two specific tools: the Perinatal Anxiety Screening Scale (PASS) and the Pregnancy-Related Anxiety Questionnaire - Revised (PRAQ-R). The PASS is a 31-item questionnaire used to screen a broad range of anxiety symptoms in perinatal women, with pregnancy-specific anxiety questions as a separate part7. The PRAQ-R is a 10-item questionnaire specifically focusing on symptoms of PSA, such as fear of giving birth, worries about bearing a physically or mentally challenged child, and concern about one's own appearance8. The risk factors for PSA are different in LMICs compared to high-income countries. Studies conducted in India and Africa have emphasized that – despite good family support and marital life – perceived stress, active depression and the number of people living in the home predicted PSA5. In high-income countries, young age, being unmarried, lower education, lower household income, being nulliparous, and having an undesired pregnancy were associated with a higher risk for PSA4. PSA has also been found to be related to pregnancy outcomes. Among Iranian women, PSA in the third trimester was associated with preterm birth. A study from the US found high levels of PSA to be significantly associated with an increased risk for spontaneous preterm birth, even after adjusting for several confounding factors. A cohort study in China found that PSA in the second and third trimesters was associated with small-for-gestational-age infants. PSA may also play a role in birth preferences, as shown by a multi-ethnic prospective cohort study from Amsterdam, which found that women with PSA were more likely to receive pain relief/sedation and had an increased risk for primary caesarean section. Another important finding is the relationship of PSA to infant temperament. In a systematic review, Erickson et al9 found an association between PSA and infant temperament in seven of the nine studies reviewed, three of which included large, representative, population-based samples. In a study of 282 mothers, PSA during second and third trimesters was significantly associated with infant's negative emotional reactivity, mainly fearfulness. PSA emerged as the only significant predictor even after controlling for background factors and for postnatal depressive and general anxiety symptoms10. PSA has also been shown to have persisting effects in the postnatal period. Wom-en who had PSA at 32 weeks of gestation exhibited clinically significant anxiety at six months postpartum even after controlling for prenatal generalized anxiety. The risk for PSA is likely to be particularly high in countries with high maternal and infant mortality rates. In African countries, maternal mortality rates range from 163 to 533 per 100,000. In some African countries, 51 per 1,000 infants may not survive their first year. In addition, pregnant women in these areas may face challenges such as food insecurity and lack of adequate maternity services, which may contribute to high levels of anxiety about their pregnancy and infant outcomes. We believe that research in the area of perinatal mental health needs to be context-specific and aim to develop useful screening and assessment methods, in addition to cost-effective interventions and services. The area of PSA may indeed be particularly relevant to LMICs. PSA needs to be regarded as a distinct entity, which may have a different clinical profile and course compared to generalized anxiety. However, it appears to be an understudied and under-recognized topic in perinatal mental health. Considering its impact on both maternal and foetal outcomes, it needs greater attention from both clinicians and researchers.