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Louise Rafferty, Perinatal Mental Health Support Midwife, Rotunda Hospital,

Anxiety in pregnancy and at three months postpartum: prevalence and co-morbidity in a cohort of first-time mothers. Trinity College Dublin. The MAMMI Study. Louise Rafferty, Perinatal Mental Health Support Midwife, Rotunda Hospital,

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Louise Rafferty, Perinatal Mental Health Support Midwife, Rotunda Hospital,

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  1. Anxiety in pregnancy and at three months postpartum: prevalence and co-morbidity in a cohort of first-time mothers. Trinity College Dublin The MAMMI Study Louise Rafferty, Perinatal Mental Health Support Midwife, Rotunda Hospital, Dr Deirdre Daly, Assistant Professor in Midwifery/Post-doctoral Researcher, Trinity College Dublin, Prof Agnes Higgins, Professor in Mental Health, Trinity College Dublin. ICHN conference 1st May 2019

  2. Acknowledgements • My supervisors and co-authors DrDéirdre Daly and Prof Agnes Higgins. • The women who participated in the Maternal health And Maternal Morbidity in Ireland study (MAMMI). • The midwives and student midwives who gave eligible women the study information. • The MAMMI study team. • The Rotunda Foundation who sponsored this research project.

  3. Overview of presentation • Background • Systematic literature search and literature review • Methodology • Findings • Key discussion points • Strengths and limitations

  4. Anxiety during pregnancy and postpartum During pregnancy Postpartum 19.4% in 2nd trimester (Dennis et al. 2017) 15.2% (5-12 weeks) 12.2% (STAI), in 2nd trimester (Figueiredo and Conde 2011)4.5% (3 months) 14.6% (CCEI), at 18 weeks (Heron et al. 2004) 8.1% (3 months)

  5. Anxiety during pregnancy and postpartumin Ireland • In Ireland, prevalence reported at 74.3% during pregnancy (Carolan-Olah and Barry 2014). No postpartum data available. • Specialist Perinatal Mental Health Services: Model for Care in Ireland report cited global estimates (HSE 2017).

  6. Systematic literature search and literature review (3685 citations– 8 studies ) Prevalence of anxiety in pregnancy Prevalence of anxiety postpartum DASS 21 anxiety subscale 12.6% (Miller et al. 2006) 13.1% (Beneret al. 2012) Depression, Anxietyand Stress Scale DASS 21 anxiety subscale • 12.4% up to 20 weeks(Huang et al. 2014) • 24% any time point(Reid et al. 2009) Edinburgh Postnatal Depression Scale EPDS 3A anxiety subscale • 17% in third trimester (Luomaet al. 2015) • 20.1% Non-Maori; • 25.2% in Maori women(Signal et al. 2017)

  7. Systematic literature search and literature review (3685 citations – 8 studies) Prevalence of depression and stress in pregnancy Prevalence of depression and stress postpartum Depression, Anxietyand Stress Scale DASS 21 depression subscale 18.6% (Miller et al. 2006) DASS 21 stress subscale 8.7% (Miller et al. 2006) Depression, Anxietyand Stress Scale DASS 21 depression subscale • 20% any time point(Reid et al. 2009) DASS 21 stress subscale • 24% any time point (Reid et al. 2009) Edinburgh Postnatal Depression Scale EPDS (> 14) depression • 15.3% Non-Maori; • 22.4% in Maori women(Signal et al. 2017)

  8. This Research Study Aim; To report prevalence of perinatal anxiety and co-morbid depression and stress in a cohort of first time mothers. Objectives; • To determine prevalence of anxiety according to the DASS 21 anxiety subscale and the EPDS 3A (cut-off scores in pregnancy and at three months postpartum. • To determine the prevalence of depression and stress according to the DASS 21 in pregnancy and at three months postpartum. • To determine the prevalence of co-morbiddepression and stressfor those mothers reporting anxiety according to the DASS 21 in pregnancy and at three months postpartum.

  9. Methods and Tools • A quantitative, longitudinal study using data from the larger MAMMI study; • Survey 1 (in pregnancy), survey 2 (3 months postpartum) and hospital records of consenting women. • Recruitment of women 1-2 weeks after their first booking visit from two urban maternity units in Ireland. • Inclusion criteria; aged 18 years or more, nulliparous and English literacy. • Exclusion criteria; miscarriage, stillbirth or sick baby in NICU. Statistical analysis; • Descriptive statistics - prevalence reported as proportions.

  10. Anxiety measurement tools Two Scales • Depression, Anxiety and Stress Scale 21 (DASS 21)(Lovibond and Lovibond 1995). • Edinburgh Postnatal Depression Scale (Cox et al. 2014) which includes three items identified as the EPDS 3A, anxiety scale (Matthey et al. 2008).

  11. DASS 21 (Lovibond and Lovibond 1995) Depression–Measuresdysphoria, hopelessness, devaluation of life, self-depreciation, lack of interest/involvement, anhedonia and inertia. Anxiety– Measures autonomic arousal, skeletal muscle effects, situational anxiety, subjective experience of anxious affect. Stress– Measures difficulty relaxing, nervous arousal, being easily agitated, irritable/over-reactive and impatience.

  12. Sample characteristics (n=1668) Differed • Age- 6.2% aged 18-25 years, compared to 19.1% (NPRS 2013) (but included all first-time mothers up to 24 years). • Health care – public health care 62.1%, compared to 81% (HIPE 2014). • Education- 68.8%, compared to 55.3% (CSO 2016). • Infant feeding – Breastfeeding 85.8%, compared to 46.3% (NPRS 2013). Comparable • Married - 62.9% comparable to 63.8% (NPRS 2013) (both nulliparous and multiparous women). • Mode of birth – Caesarean Section 31.5% comparable to 30.7% (NPRS 2013) (nulliparous only).

  13. Findings 1; Prevalence of anxiety in pregnancy and at three months postpartum, DASS 21 anxiety subscale and EPDS 3A

  14. Findings 2; Prevalence of anxiety, depression and stress according to the DASS 21

  15. Findings 3; Prevalence of anxiety only and co-morbid depression and stress for women with anxiety in pregnancy and at three months postpartum.

  16. Key Discussion points-1 New findings – • Prevalence of anxiety in pregnancy varied widely, in the same cohort of women, depending on the means of measurement. • Of those women who reported anxiety in pregnancy according to the DASS 21 anxiety subscale just over 50% had anxiety independent of depression and/or stress. • Of those women with anxiety postpartum just over 30% had anxiety alone and just under 40% had anxiety, depression and stress. • Unlike Beneret al. (2012) and Miller et al. (2006); in this study prevalence of anxiety postpartum was less than stress.

  17. Key Discussion points-2 Similar findings to other studies - • Similar to findings of Heron et al (2004) and Figueirdo & Conde (2011) - According to both anxiety measurement scales prevalence of anxiety was higher in pregnancy than at three months postpartum. • Similar to findings of Din et al. (2016) and Jonsdottiret al. (2017) (both using DASS 42), Huang et al. (2014) (using DASS 21) prevalence of anxiety was higher than depression or stress in pregnancy.

  18. Strengths and Limitations Strengths; • n=1668 nulliparous women. • Longitudinal design. • Using of two measurement scales to report prevalence. Limitations; • Prevalence may have been higher if the sample included more women in the younger age group. • The measurement scales used to report prevalence are not diagnostic tools.

  19. Role of the PHN • recognise the difference between depression and anxiety; • identify and refer women; • be aware that both coexist for a small number of women.

  20. Irish Resources Perinatal mental health: an exploration of practices, policies, processes and education needs of midwives and nurses within maternity and primary care services in Ireland. Dublin: Health Service Executive. (Higgins et al 2017)

  21. Irish Resources Perinatal Mental Health Care: Best Practice Principles for Midwives, Public Health Nurses and Practice Nurses. (Higgins et al 2017)

  22. Resources on HSEland

  23. THANK YOU

  24. References • Alonso J., Angermeyer M.C., Bernert S., Bruffaerts R., Brugha T.S., Bryson H., Girolamo G., Graaf R., Demyttenaere K., Gasquet I., Haro J.M., Katz S.J., Kessler R.C., Kovess V., Lépine J.P., Ormel J., Polidori G., Russo L.J., Vilagut G. & Almansa J. (2004) Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta PsychiatricaScandinavica109, 21-27. • Bener A., Gerber L.M. & Sheikh J. (2012) Prevalence of psychiatric disorders and associated risk factors in women during their postpartum period: a major public health problem and global comparison. International Journal of Women’s Health.4, 191-200. • Carolan-Olah M. & Barry M. (2014) Antenatal stress: An Irish case study. Midwifery30(3), 310-316. • Cox J., Holden J. & Henshaw C. (2014) Perinatal Mental Health. The Edinburgh Postnatal Depression Scale (EPDS) Manual. 2nd edn. Royal College of Psychiatrists Publications, London. • Central Statistics Office (2016) Women and men in Ireland 2016, Education. Central Statistics Office. Retrieved from www.cso.ie/en/releaseandpublications/ep/p-wamii/womenandmeninireland2016/education/ on 5th July 2018. • Dennis C.L., Falah-Hassani K. & Shiri R. (2017) Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry210, 315-323. • Din Z.U., Ambreen S., Iqbal Z., Iqbal M. & Ahmad S. (2016) Determinants of antenatal psychological distress in Pakistani women. NöroPsikiyatriArşivi53(2), 152-157. • George A., Lux R.F., Tychey C.D., Thilly N. & Spitz E. (2013) Anxiety symptoms and coping strategies in the perinatal period. BMC Pregnancy and Childbirth13, 233. • Grobman W.A., Parker C., Wadhwa P.D., Willinger M., Simhan H., Silver B., Wapner R.J., Parry S., Mercer B., Haas D., Peaceman A.M., Hunter S., Wing D., Caritis S., Esplin S., Hoffman M., Ludmir J., Iams J., Long E., Saade G. & Reddy U.M. (2016) Racial/ethnic disparities in measures of self-reported psychosocial states and traits during pregnancy. American Journal of Perinatology33(14), 1426-1432. • Henderson J. & Redshaw M. (2013) Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care. Journal of Reproductive and Infant Psychology31(5), 465-478. • Health Service Executive (2017) Specialist Perinatal Mental Health Services. Health Service Executive, Dublin.

  25. Higgins, A., Carroll, M., Downes, C., Monahan, M., Gill, A., Madden, D., McGoldrick, E. & Nagel, U. (2017) Perinatal mental health: an exploration of practices, policies, processes and education needs of midwives and nurses within maternity and primary care services in Ireland. Dublin: Health Service Executive. • Higgins, A., Carroll, M., Gill, A., Downes, C., Monahan, M. (2017) Perinatal Mental Health Care: Best Practice Principles for Midwives, Public Health Nurses and Practice Nurses. Dublin: Health Service Executive • Huang J.Y., Arnold D., Qiu C.F., Miller R.S., Williams M.A. & Enquobahrie D.A. (2014) Association of Serum Vitamin D with Symptoms of Depression and Anxiety in Early Pregnancy. Journal of Women's Health23(7), 588-595. • Jonsdottir S.S., Thome M., Steingrimsdottir T., Lydsdottir L.B., Sigurdsson J.F., Olafsdottir H. & Swahnberg K. (2017) Partner relationship, social support and perinatal distress among pregnant Icelandic women. Women and Birth30(1), e46-e55 • Kessler R.C., Petukhova M., Sampson N.A., Zaslavsky A.M. & Wittchen H.U. (2012) Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research21(3), 169-184. • LeDoux J. (2015) Anxious: Using the Brain to Understand and Treat Fear and Anxiety. Penguin, New York • Lovibond P. & Lovibond S. (1995a) Manual for the Depression, Anxiety and Stress Scale. 2nd edn. Psychology Foundation Monograph, Sydney. • Luoma I., Korhonen M., Salmelin R.K., Helminen M. & Tamminen T. (2015) Long-term trajectories of maternal depressive symptoms and their antenatal predictors. Journal of Affective Disorders170, 30-38. • Miller R.L., Pallant J.F. & Negri L.M. (2006) Anxiety and stress in the postpartum: Is there more to postnatal distress than depression? BMC Psychiatry6(12). • Reid H., Power M. & Cheshire K. (2009) Factors influencing antenatal depression, anxiety and stress. British Journal of Midwifery17(8), 501-508.

  26. Signal T.L., Paine S.J., Sweeney B., Muller D., Priston M., Lee K., Gander P. & Huthwaite M. (2017) The prevalence of symptoms of depression and anxiety, and the level of life stress and worry in New Zealand Maori and non-Maori women in late pregnancy. Australian and New Zealand Journal of Psychiatry51(2), 168-176. • Stuart G.W. (2013) Anxiety responses and anxiety disorders. In Principles and Practice of Psychiatric Nursing, 10th edn. (Stuart G.W., ed), Elsevier Health Sciences, St Louis, MO, pp. 216-243. • Wittchen H.U., Jacobi F., Rehm J., Gustavsson A., Svensson M., Jönsson B., Olesen J., Allgulander C., Alonse J., Faravelli C., Fratiglioni L., Jennum P., Lieb R., Maercker A., van Os J., Preisig M., Salvador-Carulla L., Simon R. & Steinhausen H.C. (2011) The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology21(9), 655-679. • Woolhouse H., Brown S., Krastev A., Perlen S. & Gunn J. (2009) Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study. Archives of Women's Mental Health12(2), 75-83.

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