Anxiety in the perinatal period has been found to be associated with adverse pregnancy outcomes such as low birth weight, preterm birth, and obstetric complications.[1–11] However such associations have been controversial and often contradictory, affected by factors such as research methodology, tools used, and cultural background of subjects. Research on the subject in India has been sparse and needs deliberation.
Numerous evidences have indicated that birth outcomes may be affected by various factors. Women undergo physical, physiological, social, and emotional changes during pregnancy. Prenatal anxiety has been recognized as a potential etiology leading to preterm birth (PTB) and low birth weight (LBW).[13–15] Additionally, prenatal anxiety, which has been found to be the highest in the third trimester, has been linked to somatic complaints and gestational, obstetric, and neonatal complications. However, findings on this topic have shown a relatively incongruent picture during the last few decades. Some studies reported that maternal anxiety during pregnancy was significantly associated with adverse birth outcomes such as PTB and LBW.[5,8,14,16] On the contrary, others suggested that there is no such association.[17–19] These conflicting results may be related to differences in demography and study designs. Given the inconsistent results in previous studies, this study was planned in the Indian context to examine this relationship. Anxiety symptoms and disorders are common in the perinatal period. If a positive association is found, it may help clinicians determine whether pregnant women should be regularly screened for anxiety.
MATERIALS AND METHODS
This hospital-based prospective study was conducted in the obstetrics and gynecology (OBG) department of a tertiary care hospital in collaboration with the Department of Psychiatry over a period of one year, starting from October 2017. Only those women who were in their third trimester of pregnancy, not on psychotropic medication, and with no known mental illness were considered for the study. Pregnant women presenting to the OBG department were randomly selected and screened for eligibility to be part of the study. They were recruited for the study if they consented and fulfilled the criteria. Once recruited, their general health was assessed as per the study’s parameters, and they were administered validated Hindi versions of the Perinatal Anxiety Screening Scale (PASS) and the Edinburgh Postnatal Depression Scale (EPDS) by interns trained to administer the questionnaires. The PASS is an instrument for the assessment of anxiety symptoms during pregnancy and possesses good psychometric properties. It is recommended for research and clinical use. Since comorbid depression may affect neonatal pregnancy outcomes, the same was assessed using EPDS. Demographic data was collected using a semi-structured questionnaire. According to past studies on the subject, and considering 95% confidence level and relative precision (e) of 20%, the sample size required for the study was calculated to be 130, and 195 subjects were included in the study. These women were then followed up in their postnatal period and were assessed for general health and adverse pregnancy outcomes (Apgar score, delayed cry, birth asphyxia, post-partum hemorrhage, birth weight, gestational age at birth, instrumentation or other adverse events during delivery, cesarian section, intrauterine death, and neonatal death).
Data was collected in Excel sheets and analyzed using the Statistical Package for the Social Sciences version 21 (IBM). Apart from the Chi-squared test for the difference between groups, correlation coefficients were calculated to ascertain the relationship between variables. Ethical clearance from the institutional ethics committee was obtained before the start of the study. All enrolled women were offered treatment in case they were found to have high anxiety levels.
A total of 195 pregnant women were recruited and all completed the study. Demographic parameters are summarized in Table 1. Forty-nine percent of the women (n = 95) were in the age group 26–30 years. Eleven percent were primigravida while 49% were second para. All recruited women were educated till at least high school and 48% were graduates. Ten percent of the women reported bad obstetric history, and 30% reported suffering from some medical illness. Adverse pregnancy outcomes, as defined in the study, was reported in 50.8% (n = 99) of patients [Table 2]. Nineteen women (9.74%) had a high PASS score (between 42 and 93), out of which only 8 had adverse pregnancy outcomes and 11 did not, and there was no association between adverse pregnancy outcomes and PASS scores (Pearson’s χ2 = 3.457, P = 0.178) [Table 3]. Even when the modes of delivery and low birth weight were considered separately, no association was found. Furthermore, 44 women (22.6%) had an EPDS score of more than 10, but again there was no association of high EPDS score and adverse pregnancy outcomes [Table 4]. There was no correlation between the EPDS and PASS scores [Table 5]. Those women with high PASS or EPDS scores were offered treatment options. None of them consented for pharmacotherapy, but some were administered supportive psychotherapy when they opted for it. Clinical evaluation did not reveal any syndromal psychopathology in any of the women with high PASS or EPDS score.
In our study, we found no association between perinatal anxiety and adverse pregnancy outcomes. Our findings are contrary to most reported data worldwide. A recent meta-analysis by Ding et al. reported that increased pregnancy-related anxiety was associated with low birth weight and preterm births. However most of the studies included in this meta-analysis were from the West and none from India. Moreover, most of the studies used the State-Trait Anxiety Inventory (STAI) for the measurement of anxiety in these women, which is not a specific instrument for measuring perinatal anxiety. Hence the results are likely to be different.
Another similar study from Goa (India) reported a positive correlation between antenatal psychopathology and low birth weight. It used the General Health Questionnaire to assess psychopathology, and the paper came out of a secondary analysis of the data.
A recent meta-analysis similarly claimed a robust association between maternal antenatal anxiety and adverse pregnancy outcomes. Again, this meta-analysis did not include any study from Southeast Asia and most of the instruments used for assessment of anxiety were general anxiety questionnaires.
The strength of the current study was its use of a measure of anxiety screening that covered a wide range of problems associated with pregnancy and assessed anxiety symptoms more accurately.
Absence of clinically significant anxiety could be due to a variety of reasons. Socioeconomic and domestic factors play a role in causation of anxiety. All the women included in the study belonged to families with stable source of income and adequate family support. This is because the hospital where the study was carried out caters to personnel from a particular industrial group who have access to quality health care. Additionally, most of the women were educated (at least till high school), had support at home, and were living with either their mothers or mothers-in-law for care during pregnancy, as is the culturally prevalent norm in Indian families. Robust support system, lack of risk factors, and psychosocial support could be a reason for reduced anxiety levels.
Absence of the association between perinatal anxiety and adverse pregnancy outcomes could be simply because anxiety does not affect pregnancy. Associations discerned in the past have been controversial and based on statistics. A conclusive evidence of the cause of adverse pregnancy outcomes due to anxiety has not yet been proven and the subject still needs to be studied.
Another reason for the lack of correlation could be stigma of mental illnesses. Although all attempts were made to make a rapport with and explain the research to the patients, social stigma may have prevented them from disclosing their symptoms. Lack of psychological awareness of the recruited women could be another cause of underreporting of symptoms.
An interesting observation in the study was the presence of higher anxiety scores in women who had no adverse pregnancy outcomes, though the result was not statistically significant. It is possible that anxious women resorted to help-seeking and better care, resulting in better pregnancy outcomes. More research is needed to examine this relationship. High EPDS scores, which indicate depression in the subjects, were found in 22.6% of women, but there was no association of the same with either PASS scores or with adverse pregnancy outcomes. However, it may be noted that clinical evaluation did not reveal syndromal psychopathology in these women, which could be the reason why no association was found.
Strengths of the study were a prospective design, and use of specific scales for measurement of anxiety and depression. A major drawback of the study is that it cannot be generalized, since the clientele consisted of members of a particular socio-occupational group having access to quality health care and better socioeconomic status than most Indians. Another possible drawback is selection bias. Since the study was voluntary, those women suffering from higher levels of anxiety may have refused to participate in the study.
Nevertheless, some lessons can be drawn from the study. Despite the study not being generalizable, it can be observed that pregnancy outcomes can be better with adequate support and medical care. Similarly, anxiety and depression can be minimized in pregnant women for better pregnancy outcomes. The current study is one of its kind in India, reporting preliminary data on the subject. Further studies are required to replicate the results in order to the lay the foundation for better mental health care for women in the antenatal period.
No intervention was planned in the study and the participating women were offered treatment as usual. Institutional ethics committee clearance was obtained and confidentiality of data was maintained. Written and informed consent was obtained from participants.
No significant association was observed between antenatal anxiety and adverse pregnancy outcomes in the current study. Though results are not generalizable to the population, the study provides a foundation for similar studies to assess the relationship between anxiety and adverse pregnancy outcomes in Indian women, which can help in providing better antenatal care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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