PREVALENCE

• In this study, more than half of the pregnant women (55.7%) were suffering from pregnancy-related anxiety during earlyto-mid pregnancyas determined by using the PRT scale.
• The reported prevalence rates using differing scales from other countries seem to be much lower- 23.6% in Saudi Arabia using the State Anxiety scale,21 26.8% in Brazil using the Hospital Anxiety Subscale,22 23% in South Africa using the Mini-International Neuropsychiatric Interview diagnostic interview and 25% in Tanzania using the Pregnancy-related anxiety questionnaire.23,24 Among Indian studies, Madhavaprabhakaran et al25 with the help of the Pregnancy Specific Anxiety Scale (PSAS), found that all women during the first trimester had some degree of pregnancy specific anxiety, which was mostly the moderate form in 89.4% of the women. A lower prevalence rate of 28.4% throughout all the trimesters was seen among pregnant women in Bhubaneswar for which the Hospital Depression and Anxiety Scale was used for measurement.26 This disparity in the prevalence rates could be attributed to differences in the psychometric properties of measuring scales that were used; and also to the sociodemographic and sociocultural heterogeneity and diversity of the study population. Societal norms and values can also alter the perceptions of what may be considered to be “stressful” or “dangerous” hence accounting for this variation in the prevalence across different study settings.27

ref: 

0 - Nath A, Venkatesh S, Balan S, Metgud CS, Krishna M, Murthy GVS. The prevalence and determinants of pregnancy-related anxiety amongst pregnant women at less than 24 weeks of pregnancy in Bangalore, Southern India. Int J Womens Health. 2019;11:241-248. Published 2019 Apr 10. doi:10.2147/IJWH.S193306

21. Alqahtani AH, Al Khedair K, Al-Jeheiman R, Al-Turki HA, Al Qahtani NH. Anxiety and depression during pregnancy in women attending clinics in a university hospital in eastern province of Saudi Arabia: prevalence and associated factors. Int J Womens Health. 2018;10:101–108. doi:10.2147/IJWH.S153273

22. Silva MMJ, Nogueira DA, Clapis MJ, Leite EPRC. Anxiety in pregnancy: prevalence and associated factors. Rev Esc Enferm USP. 2017;51:e03253. doi:10.1590/S1980-220X2016048003253

23. van Heyningen T, Honikman S, Myer L, Onah MN, Field S, Tomlinson M. Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study. Arch Womens Ment Health. 2017;20 (6):765–775. doi:10.1007/s00737-017-0768-z

24. Wall V, Premji SS, Letourneau N, McCaffrey G, Nyanza EC. Factors associated with pregnancy-related anxiety in Tanzanian women: a cross sectional study. BMJ Open. 2018;8(6):e020056. doi:10.1136/ bmjopen-2017-020056

25. Madhavanprabhakaran GK, D’Souza MS, Nairy KS. Prevalence of pregnancy anxiety and associated factors. IJANS. 2015;3:1–- 7.10.1016/j. ijans.2015.06.002.

26. Priyambada K, Pattojoshi A, Baklava AK. A study of antenatal anxiety: comparison across trimesters. Int J Reprod Contracept Obstet Gynecol. 2017;6(5):1810–1813. doi:10.18203/2320-1770. ijrcog20171504

27. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer; 1984.

SOCIODEMOGRAPHIC FACTORS

Among the sociodemographic factors, we could not demonstrate any relevant association of pregnancyrelated anxiety with age, respondent’s education and occupation; and husband’s education.

Madhavaprabhakaran et al25 reported that younger women were at a higher risk for pregnancy-related anxiety.

In regard to the relationship of anxiety with a woman’s education, different studies report conflictive findings. While Lau and Yin28 (2011) contended that well educated women could handle stress in a better way during pregnancy;28 other authors claim that the stress levels could be much higher in this group.29,30

The burden of anxiety was seemingly higher among women who belonged to lower socioeconomic classes; which is in concurrence with other study results.31–34 However, Kingston et al35 (2012) and Renae Stancil et al36 (2000), found lower levels of stress in lower income group women.

REF

28. Lau Y, Yin L. Maternal, obstetric variables, perceived stress and health-related quality of life among pregnant women in Macao, China. Midwifery. 2011;27(5):668–673. doi:10.1016/j.midw.2010. 02.008 29. Goyal D, Gay C, Lee KA. How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Women’s Health Issues. 2010;20(2):96–104. doi:10.1016/j.whi.2009.11.003 30. Woods SM, Melville JL, Guo Y, Fan M-Y GA. Psychosocial stress during pregnancy. Am J Obstet Gynecol. 2010;202(1):e61–e67. doi:10.1016/j.ajog.2009.07.041 31. Shishehgar S, Dolatian M, Majd HA, Bakhtiary M. Socioeconomic status and stress rate during pregnancy in Iran. Glob J Health Sci. 2014;6 (4):254–260. 10.5539/gjhs.v 6n4p254. DOI:10.5539/gjhs.v6n4p254

32. Farkas C, Valdés N. Maternal stress and perceptions of self-efficacy in socioeconomically disadvantaged mothers: an explicative model. Infant Behav Dev. 2010;33(4):654–662. doi:10.1016/j.infbeh.2010.09.001 33. Lever JP. Poverty, stressful life events, and coping strategies. Span J Psychol. 2008;11(1):228–249. doi:10.1017/S1138741600004273 34. Matthews KA, Gallo LC, Taylor SE. Are psychosocial factors mediators of socioeconomic status and health connections? Ann N Y Acad Sci. 2010;1186(1):146–173. 10.1111/j.1749-6632.2009.05332. x. DOI:10.1111/j.1749-6632.2009.05332.x 35. Kingston D, Heaman M, Fell D, Dzakpasu S, Chalmers B. Factors associated with perceived stress and stressful life events in pregnant women: findings from the Canadian maternity experiences survey. Matern Child Health J. 2012;16(1):158–168. doi:10.1007/s10995- 010-0732-2

36. Renae Stancil T, Hertz-Picciotto I, Schramm M, Watt-Morse M. Stress and pregnancy among African-American women. Paediatr Perinat Epidemiol. 2000;14(2):127–135. doi:10.1046/j.1365-3016.2000.00257.x

OBSTETRIC HISTORY

In the current study, previous pregnancy loss and unplanned pregnancy significantly predict antinatal anxiety. Hypertension, anaemia, and planned mode of delivery and gravidity/parity are other potential risk factors identified by some authors even if the results are also contradictory. For example, Nath and colleagues [0] reported higher levels of anxiety among primiparous women, while multigravidity was reported to be associated with antenatal anxiety by Heyningen et al. These latter findings of the aggravating effects of primiparity and multigravidity deserves further studies to identify the role of 'bad obstetric history' or preveious pregnancy loss as a mediator. Given that a primparous woman could also be referred to as multigravid if she has a history of abortion, which could have predisposed to anxiety relating recurrence of loss of pregnancy, further research is needed to clarify the nature of the relationship. This mediating effect of loss of pregnancy is in agreement with the findings by Algahtani et al that history of abortion is a significant predictor of anxiety. Similarly, a study by van Heyningen et al confirmed that previous pregnancy loss among multigravid but not multiparous women, did predispose to prenatal anxiety. 

We could not find any important linkage between anxiety and obstetric history, although many studies show higher levels of anxiety among primiparous women.37,38 Also, an unplanned pregnancy or a history of medical complaint did not appear to predispose to prenatal anxiety. This is contrary to the study findings on anxiety in pregnant women from the Netherlands wherein multiparity, a history of depression, episodes of severe nausea and extreme fatigue were strongly related with anxiety.39 Alqahtani et al21 in their research, also identified unplanned pregnancy and history of abortion to be significant predictors of anxiety.21 Likewise, van Heyningen et al23 confirmed that multigravidity, previous pregnancy loss and unplanned pregnancy could be significant predictors of antenatal anxiety.

REF

37. Öhmann SG, Grunewald C, Walndenström U. Women’s worries during pregnancy: testing the Cambridge Worry Scale on 200 Swedish women. ScandJ Caring Sci. 2003;17:148–152 10. 1046/j.1471-6712.2003. 00095.x. doi:10.1046/j.1471-6712.2003. 00095.x. 38. Lobel M, Cannella DL, Graham JE, DeVincent C, Schneider J, Meyer BA. Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychol. 2008;27:604–615. doi:10.1037/ a0013242 39. van de Loo KFE, Vlenterie R, Nikkels SJ, et al. Depression and anxiety during pregnancy: the influence of maternal characteristics. Birth. 2018;45:478–489. doi:10.1111/birt.12343

21. Alqahtani AH, Al Khedair K, Al-Jeheiman R, Al-Turki HA, Al Qahtani NH. Anxiety and depression during pregnancy in women attending clinics in a university hospital in eastern province of Saudi Arabia: prevalence and associated factors. Int J Womens Health. 2018;10:101–108. doi:10.2147/IJWH.S153273 22. Silva MMJ, Nogueira DA, Clapis MJ, Leite EPRC. Anxiety in pregnancy: prevalence and associated factors. Rev Esc Enferm USP. 2017;51:e03253. doi:10.1590/S1980-220X2016048003253 23. van Heyningen T, Honikman S, Myer L, Onah MN, Field S, Tomlinson M. Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study. Arch Womens Ment Health. 2017;20 (6):765–775. doi:10.1007/s00737-017-0768-z

PSYCHOSOCIAL FACTORS

Among the psychosocial factors, low social support emerged as a significant predictor of anxiety. The association of anxiety with marital discord was weak whereas none was seen with a recent history of catastrophic events. While spousal violence is a known stressor,40,41 paradoxically, in the present study the prevalence of anxiety was seemingly lower in respondents who were victims; this may be ascribed to a respondent bias in the form of nonreporting, most likely due to fear apprehension or an associated social stigma. Most cases of spousal violence go under-reported, the reported cases present the “tip of the iceberg.” 42 Increased perceived social and partner support appear to decrease the risk for antenatal anxiety as observed in other study settings.43 The prevalence of anxiety was significantly higher among women who were depressed in the present study. The co-morbid existence of depression and anxiety is frequently encountered, although the mechanism behind this and timing of which appears first is yet to be ascertained.24,

REF LISTS https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489575/pdf/ijwh-11-241.pdf

PREVALENCE

Prevalence 23.3%

In  this study, more than a third of the our participants suffered from antenatal anxiety (29.3%, 95% CI 26.2 - 31.3), which is consistent with previous reports of the high burden of pregnancy-related anxiety. By contrast, lower prevalence has been reported from other settings, while much higher figures have been quoted by some authors. The variation in the prevalence could be attributed to differences in the scales used for measuring anxiety in the various studies, as each scale has its unique psychometric property, making it disorder-specific or only suitable for screening. For example, the prevalence rates by measurement scales were: 24% with State Anxiety Scale in Saudi Arabia, 27% using Hospital Anxiety Subscale in Brazil, 23% with use of Mini-International Neuropsychiatric Interview in South Africa, and 25% with Pregnancy-related anxiety questionnaire in Tanzania. Other reasons accounting for the disparity in prevalence rates across different study settings onclude variations in socio-economic factors, cultural values and trimester of measurements and sampling methodological differences and measurement errors. Although the magnitude of antenatal anxiety vary significiatlly across different reports for different reasons, the prevalence rates show that pregnancy-related anxiety is a common and significant burden that has become a publich health issues, especially in LMICs.

China 20.6% - Trimester 3- Kang YT, Yao Y, Dou J, et al. Prevalence and Risk Factors of Maternal Anxiety in Late Pregnancy in China. Int J Environ Res Public Health. 2016;13(5):468. Published 2016 May 4. doi:10.3390/ijerph13050468

Brazil SA 58.5%, TA - 53.2% - Caroline R.F., Mayara C.O., Camilla R.V., Andrea M.A.P., Roberta R.S. Prevalence of anxiety symptoms and depression in the third gestational trimester. Arch. Gyn. Obstet. 2015;291:999–1003

Singapore 12.5% - Thiagayson P., Krishnaswamy G., Lim M.L., Sung S.C., Haley C.L., Funf D.S.S., Allen J.C., Chen H. Depression and anxiety in Singaporean high-risk pregnancies-prevalence and screening. Gen. Hosp. Psychiatry. 2013;35:112–117. doi: 10.1016/j.genhosppsych.2012.11.006.

Reasons for differing prevalence:

1. T3 in china , with physical discomfort - Costa D.D., Larouche L., Dritsa M., Brender W. Variations in stress levels over the course of pregnancy: Factors associated with elevated hassles, state anxiety and pregnancy-specific stress. J. Psychosom. Res. 1999;47:609–621. doi: 10.1016/S0022-3999(99)00064-1

2. sampling methodologies and measurement errors - Janice H.G., Kerry L.C., Marlene P.F. Anxiety disorders during pregnancy: A systematic review. J. Clin. Psychiatry. 2014;75:e1153–e1184.

PRT scale Bangalore 55.7% <24wks. - Nath A, Venkatesh S, Balan S, Metgud CS, Krishna M, Murthy GVS. The prevalence and determinants of pregnancy-related anxiety amongst pregnant women at less than 24 weeks of pregnancy in Bangalore, Southern India. Int J Womens Health. 2019;11:241-248. Published 2019 Apr 10. doi:10.2147/IJWH.S193306

SA Scale 23.6% Saudi- Alqahtani AH, Al Khedair K, Al-Jeheiman R, Al-Turki HA, Al Qahtani NH. Anxiety and depression during pregnancy in women attending clinics in a university hospital in eastern province of Saudi Arabia: prevalence and associated factors. Int J Womens Health. 2018;10:101–108. doi:10.2147/IJWH.S153273

26.8% in Brazil using the Hospital Anxiety Subscale - Silva MMJ, Nogueira DA, Clapis MJ, Leite EPRC. Anxiety in pregnancy: prevalence and associated factors. Rev Esc Enferm USP. 2017;51:e03253. doi:10.1590/S1980-220X2016048003253

23% in South Africa using the Mini-International Neuropsychiatric Interview diagnostic interview - van Heyningen T, Honikman S, Myer L, Onah MN, Field S, Tomlinson M. Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study. Arch Womens Ment Health. 2017;20(6):765–775. doi:10.1007/s00737-017-0768-z

25% in Tanzania using the Pregnancy-related anxiety questionnaire- Wall V, Premji SS, Letourneau N, McCaffrey G, Nyanza EC. Factors associated with pregnancy-related anxiety in Tanzanian women: a cross sectional study. BMJ Open. 2018;8(6):e020056. doi:10.1136/bmjopen-2017-020056

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SOCIODEMOGRAPHICS

Among the sociodemographic factors, lack of educational achievement emerged as a significant predictor of antenatal anxiety which is in concurrence with other study results [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881093/  and https://www.annals.edu.sg/pdf/47VolNo10Oct2018/MemberOnly/V47N10p405.pdf%20Antenatal%20Anxiety:%20Prevalence%20and%20Patterns%20in%20a%20Routine%20Obstetric%20Population] . Specifically, an inverse relationship between "literacy" and antenatal anxiety was reported in a study from Bangladesh. By contrast, "more years of schooling" was found to be associated wtih adverse mental health conditions, particularly anxiety and depression from other studies, even if a few studies did not find any significant assocaition between  educational attainment and antental anxiety.  Literacy is correlated with higher socioeconomic status, and well educated people are more likely to enjoy a better and have greater access to health and health informations than their less educated counterparts. This advantage conferred by education might have been protective against anxiety or depression, and given the high premium placed on literacy in Nigeria, with up more than half of the repsondents having post-secondary education, this finding merit a closer investigation to elucidate the exact relationship between education and mental health. This is more so as even when corrected for employment rates and income, lower education remain independently associated with anxiety symptoms in pregnancy