Research report
Maternal anxiety during the transition to parenthood: A prospective study

https://doi.org/10.1016/j.jad.2007.10.002Get rights and content

Abstract

Background

This prospective study used both self-report (STAI) and clinical diagnostic interview (MINI-Plus) to examine the course of maternal anxiety across the transition to parenthood. The study also assessed i) the validity of the STAI for antenatal use in an Australian sample and ii) the relative utility of the MINI-Plus and STAI scales as antenatal measures of risk for postnatal anxiety and mood disorders.

Methods

Participants were 100 women recruited during routine antenatal assessment at a major obstetric hospital in Sydney. An antenatal screening instrument (ANRQ) identified half the sample as being at “high risk” for developing postnatal anxiety and/or depression. Participants completed the STAI during the third trimester of pregnancy and the MINI-Plus was administered during pregnancy and during the seventh postnatal month to assess anxiety and depression meeting DSM-IV criteria.

Results

The data indicated considerable stability in anxiety and depression from pregnancy through the postnatal period, as assessed by both diagnostic interview and maternal self-report. Antenatal anxiety meeting diagnostic criteria and antenatal trait anxiety exceeding a cut-off score of 40 on the STAI were both found to be significant predictors of postnatal anxiety and mood disorders (p-values < .05). Further analyses revealed that the measures were equivalent in their predictive utility. Finally, the STAI state and trait anxiety scales demonstrated a reasonable estimation of antenatal clinical state when tested against the MINI-Plus diagnostic interview during pregnancy.

Conclusions

The findings from this study suggest that antenatal anxiety as assessed by either clinical interview or maternal self-report is an important predictor of postnatal anxiety and mood disorders. The validity of the STAI scales for use during pregnancy was also demonstrated for the first time in an Australian sample.

Introduction

There is a clear need for a better understanding of patterns of maternal anxiety across the transition from pregnancy to parenthood. Several recent studies suggest that psychological distress during the perinatal period may have a negative impact on both maternal postnatal mental health and offspring development. Anxiety during pregnancy has been linked to negative expectations about motherhood (Hart and McMahon, 2006), difficulties adjusting to the demands of the maternal role (Barnett et al., 1991), and the development of other forms of distress, particularly postnatal depression (Austin et al., 2007, Heron et al., 2004, Matthey, 2004, Matthey et al., 2003, Sutter-Dallay et al., 2004). An emerging literature also indicates that maternal antenatal psychological state is associated with fetal neurobehavioural functioning (DiPietro et al., 2003, DiPietro et al., 2002, Monk et al., 2000), and with the development of difficult infant temperament (Austin et al., 2005b, Huizink et al., 2002, Werner et al., 2007), developmental delays (Brouwers et al., 2001, Buitelaar et al., 2003, Huizink et al., 2003, Laplante et al., 2004), and other emotional and behavioural disturbances in childhood (O'Connor et al., 2003, Van den Bergh and Marcoen, 2004). Following birth, high levels of maternal anxiety may contribute to suboptimal child development, possibly mediated by dysfunctional parenting behaviours such as reduced sensitivity (Nicol-Harper et al., 2007, Warren et al., 2003) and over-control (Whaley et al., 1999). Thus, antenatal anxiety may be an important early marker that could be used to identify women at risk for compromised mental health and offspring outcomes. Few studies, however, have systematically investigated the course of maternal anxiety across the transition to parenthood and results from existing studies are equivocal.

Several conceptual and methodological limitations in the research to date have constrained the generalisability of findings and made the comparison of results across studies difficult. One important limitation is the inconsistency with which perinatal anxiety is defined and operationalised. Approaches to the measurement of perinatal anxiety include dispositional indicators such as trait anxiety (e.g., Austin et al., 2005b, Field et al., 2003) and worry (Austin et al., in press), indicators of general state anxiety (e.g., Davis et al., 2004, Van den Bergh and Marcoen, 2004, Van den Bergh et al., 2005), and anxiety specifically related to pregnancy (e.g., Gutteling et al., 2005a, Gutteling et al., 2005b, Huizink et al., 2004). Although some groups have started to explore similarities and differences among measures of perinatal anxiety (Austin et al., 2007, Huizink et al., 2004), further work testing their conceptual equivalence and their differential utility in predicting maternal mental health and offspring outcomes is needed.

A related issue requiring further attention is the validation of anxiety inventories for use in perinatal research. Very few studies use diagnostic interviews for the assessment of antenatal and/or postnatal anxiety, with most relying on self-report measures such as the Crown-Crisp Experiential Index (CCEI: Crisp et al., 1978) and the State–Trait Anxiety Inventory (STAI: Spielberger et al., 1987). Although widely used in the general population, most self-report anxiety instruments are yet to be validated for use with pregnant and postnatal women. Given the substantial psychological, social, and physiological changes that often accompany pregnancy and childbirth, the establishment of appropriate clinical cut-offs and norms for use during the perinatal period is essential for interpreting the clinical significance of research findings and facilitating meaningful cross-study comparisons.

Finally, self-report measures are subject to mood-related reporting biases and these may be particularly salient when assessments are conducted during pregnancy or during the first few weeks following birth. In studies where the measures are administered retrospectively (e.g., Brockington et al., 2006), there is the additional risk of memory bias or forgetfulness about crucial events. While prospective studies may overcome some of the shortcomings associated with retrospective reporting, the data is currently limited.

The present study adds to the existing literature by using a prospective design and both diagnostic interviews and self-report measures to assess patterns of maternal anxiety from pregnancy through 7 months following birth. Given the widespread use of self-rating scales and the dearth of validation data, the study also explores the relative utility of diagnostic clinical interviews and symptom checklists as predictors of postnatal anxiety and mood disorders.

Section snippets

Participants

Participants were women taking part in a prospective longitudinal project investigating the influence of antenatal psychosocial factors on fetal neurobehaviour, child development, and maternal adjustment to parenthood. The study was approved by the relevant institutional ethics review committees and all participants provided written consent. Recruitment took place during routine antenatal psychosocial assessment at clinics at the Royal Hospital for Women, Sydney and nearby private clinics.

Socio-demographic characteristics of participants

The sample consisted of predominantly Caucasian (93%) and highly educated women, with most (81%) having attained tertiary level education (55% university and 26% technical colleges). Mean age was 31.97 years (SD = 4.43 years, range = 20–43 years). Ninety percent (n = 90) of women had a partner at the time of recruitment and 70% (n = 70) were expecting their first baby. While five women reported smoking (defined as ≥ 5 cigarettes/day) during pregnancy, none reported an alcohol intake of > 2 standard

Discussion

The present study demonstrates that anxiety and depression were stable from pregnancy through 7 months following birth and that antenatal anxiety meeting diagnostic criteria and self-reported trait anxiety were comparable and reliable predictors of postnatal anxiety and depression meeting DSM-IV diagnostic criteria. These findings confirm and extend previous studies in which the measurement of antenatal and/or postnatal anxiety and mood has relied on maternal self-report (Heron et al., 2004,

Limitations

Several limitations of the study need to be considered. First, we acknowledge that there is some potential for selection bias in our sample as demographic data for those who declined participation were not available for analysis. We were, however, able to compare participants and non-participants on their antenatal screening assessments, and found no differences between study participants and those who declined. Secondly, the current study used a sample in which women at high risk for postnatal

Conclusions

Notwithstanding the above limitations, the present data adds to the literature by using prospective methodology and both diagnostic interview and self-report to examine the course of maternal anxiety across the transition to parenthood. The results suggest that women with an antenatal anxiety disorder or women reporting elevated levels of self-reported trait anxiety were significantly more likely to meet diagnostic criteria for an anxiety or mood disorder during the seven months following

Role of the funding source

Funding for this study came from a NH&MRC Program Grant (157209) and a NSW Centre for Mental Health Infrastructure Grant. The funding sources had no further role in study design; the collection, analysis and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

There are no conflicts of interest, actual or potential, related to the submitted manuscript.

Acknowledgements

Our thanks go to the women who participated in this study, to Nicole Reilly for co-ordinating data collection, and to Dr Alan Taylor (Macquarie University) for statistical advice.

References (56)

  • HuizinkA.C. et al.

    Is pregnancy anxiety a distinctive syndrome?

    Early Hum. Dev.

    (2004)
  • LecrubierY. et al.

    The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI

    Eur. Psychiatr.

    (1997)
  • MattheyS. et al.

    Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety?

    J. Affect. Disord.

    (2003)
  • Nicol-HarperR. et al.

    Interactions between mothers and infants: impact of maternal anxiety

    Infant. Behav. Dev.

    (2007)
  • ParkerG. et al.

    The influence of anxiety as a risk to early onset major depression

    J. Affect. Disord.

    (1999)
  • SheehanD.V. et al.

    The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability

    Eur. Psychiatr.

    (1997)
  • Sutter-DallayA.L. et al.

    Women with anxiety disorders during pregnancy are at increased risk of intense postnatal depressive symptoms: a prospective survey of the MATQUID cohort

    Eur. Psychiatr.

    (2004)
  • WadhwaP.D.

    Psychoneuroendocrine processes in human pregnancy influence fetal development and health

    Psychoneuroendocrinology

    (2005)
  • WarrenS.L. et al.

    Maternal panic disorder: infant temperament, neurophysiology, and parenting behaviors

    J. Am. Acad. Child Adolesc. Psych.

    (2003)
  • WilhelmK. et al.

    The relationship between interpersonal sensitivity, anxiety disorders and major depression

    J. Affect. Disord.

    (2004)
  • AustinM.-P.

    Psychosocial assessment and the management of depression and anxiety during pregnancy: key aspects of antenatal care for general practice

    Aust. Fam. Physician

    (2003)
  • AustinM.-P. et al.

    Antenatal screening for the prediction of postnatal depression: validation of a psychosocial pregnancy risk questionnaire

    Acta Psychiatr. Scand.

    (2005)
  • Austin, M.-P., Tully, L., Parker, G., 2007. Examining the Relationship Between Antenatal Anxiety and Postnatal...
  • BarkerD.J.P.

    In utero programming of chronic disease

    Clin. Sci.

    (1998)
  • BarnettB. et al.

    Possible determinants, correlates and consequences of high levels of anxiety in primiparous mothers

    Psychol. Med.

    (1986)
  • BarnettB. et al.

    Maternal anxiety: a 5-year review of an intervention study

    J. Child Psychol. Psychiatry

    (1991)
  • BoyceP. et al.

    The development of a brief personality scale to measure vulnerability to postnatal depression

    Arch. Womens Ment. Health

    (2001)
  • BrockingtonI.F. et al.

    Anxiety, obsessions and morbid preoccupations in pregnancy and the puerperium

    Arch Women Ment Health

    (2006)
  • Cited by (374)

    View all citing articles on Scopus
    View full text