Understanding women’s perspectives on this topic is important because:
- Perinatal anxiety (anxiety during pregnancy and postpartum) is relatively common and can have significant impacts on maternal and child health.
- Routine screening can help identify women who may benefit from support or treatment.
- Women’s views can inform how healthcare providers implement such screenings to make them more acceptable and effective.
Yuill, C., Sinesi, A., Meades, R., Williams, L. R., Delicate, A., Cheyne, H., ... & Walker, J. J. (2024). Women's experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study. British Journal of Health Psychology. https://doi.org/10.1111/bjhp.12740
Key Points
- The primary methods of assessing perinatal anxiety include questionnaires and interviews with pregnant and postpartum women.
- Factors like stigma, trust in healthcare providers, and personalized care significantly affect women’s engagement with and acceptance of perinatal anxiety assessments.
- The research, while enlightening, has certain limitations such as a lack of diversity in the sample population.
- Understanding women’s experiences with perinatal anxiety assessment is universally relevant for improving maternal mental health care and outcomes.
Rationale
Perinatal anxiety affects approximately 20% of women during pregnancy and up to one year after birth (Fawcett et al., 2019).
While depression during the perinatal period has been well-researched, anxiety has only recently received significant attention.
Current guidelines in countries like the UK recommend routine screening for perinatal anxiety, but there is limited research on women’s experiences and views of these assessments.
Previous studies have shown that women generally find mental health assessments during antenatal care acceptable (Yapp et al., 2019).
However, research has also revealed women’s reluctance to disclose mental health problems due to fear of stigma and being seen as a ‘bad mother’ (Button et al., 2017; Coates et al., 2014).
Additionally, barriers to accessing support and treatment have been identified, such as insufficient staff time and unclear referral pathways (Ford, Shakespeare, et al., 2017).
The next step in this field of research is to explore women’s experiences and views of routine assessment for anxiety across the entire perinatal period, which can inform the delivery of assessment during antenatal and postnatal care.
Method
This study employed a qualitative approach using semi-structured interviews.
The interviews consisted of two parts: an in-depth exploration of women’s experiences of perinatal mental health assessment and views on the acceptability of assessment measures, and a cognitive interview study (reported elsewhere).
Interviews were conducted by three psychology researchers experienced in qualitative interviewing.
They lasted up to 95 minutes in total and explored participants’ experiences and views of acceptability of different assessments for perinatal mental health, specifically the Clinical Outcomes in Routine Evaluation (CORE-10), Generalized Anxiety Disorder 7-item (GAD-7), Stirling Antenatal Anxiety Scale (SAAS), and Whooley questions.
The topic guide was developed based on Sekhon et al.’s (2017) theoretical framework of acceptability of health interventions, which includes seven indicators: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy.
Data analysis was conducted using thematic analysis, following Braun and Clarke’s (2006) iterative process. The analysis used both deductive coding based on Sekhon et al.’s framework and inductive open coding to capture emergent themes.
Sample
The study included 41 pregnant or postnatal women. Participants were eligible if they were pregnant or within 6 weeks of giving birth, aged 16 or over, and had sufficient English language skills.
They were recruited through UK organizations such as the NCT, Maternal Mental Health Change Agents Scotland, and the Maternal Mental Health Alliance.
Participants were purposively sampled according to pregnancy gestation at 12 weeks (n = 6), 22 weeks (n = 6), 31 weeks (n = 13) and 6 weeks postpartum (n = 16) in England and Scotland.
The sample included women who scored above and below thresholds on measures recommended by NICE guidelines for assessing anxiety and depression.
The majority of participants were pregnant (61%), White Caucasian (93%), employed (93%), and educated to degree level or above (85%). Twenty-nine participants had experienced lifetime mental health problems, with 23 of these having received treatment.
Results
The study identified six main themes:
1. Raising awareness
Participants emphasized that regular assessments could help women recognize and acknowledge their own mental health status.
This increased self-awareness was seen as a potential catalyst for seeking help or implementing self-care strategies.
Additionally, the normalization of mental health discussions through assessments was viewed as a step towards reducing societal stigma surrounding perinatal mental health issues.
“Even if you did just do the questionnaire and didn’t talk about it, even if it wasn’t really expanded, it would make me more self-aware of my mental health, it would become quite normal then for me maybe to become a bit more self-aware.”
(SP07)
2. Improving support
Women highlighted that early identification of anxiety through assessments could lead to proactive support measures.
They expressed that tailored interventions based on assessment results could potentially prevent the escalation of mental health issues.
Furthermore, participants saw assessments as a way to track their mental health journey throughout the perinatal period, allowing for adjustments in support as needed.
“It would have been good to be asked questions in pregnancy, because I was really anxious during pregnancy and maybe if I’d have been asked some questions or given some kind of questionnaires, it might have flagged to someone that this person is anxious, so therefore when she has the baby, we should check in on her…”
(EP04)
3. Surveillance and stigma
Some women expressed concern that assessments might be used to judge their parenting abilities, potentially leading to interventions from social services.
This fear of judgment and its consequences could result in women downplaying or concealing their true mental state during assessments.
The perception of being watched or evaluated added an extra layer of stress to an already challenging period for some participants.
“I think if I was … say if I was worried about my ability to parent, and then I was admitting to someone that I struggled with my worries and struggled with my thoughts then I would possibly hide that.”
(EP08)
4. Gatekeeping
Participants worried that scoring systems might create arbitrary cut-offs for accessing specialized mental health services.
They expressed concern that women with significant needs might be overlooked if they didn’t meet specific scoring thresholds.
Some also felt that the reliance on assessment scores might oversimplify the complex nature of perinatal mental health experiences.
“For me, it’s to almost like a qualification to get in to access certain services basically. I feel like if I haven’t scored ‘high enough’ on the questionnaires, I would’ve not been referred to the perinatal mental health team…”
(EP01)
5. Personalized care
Women emphasized the importance of healthcare providers considering individual circumstances and experiences when interpreting assessment results.
They expressed a desire for assessments to be part of a broader, ongoing conversation about their mental health rather than a one-time event.
Participants also highlighted the need for flexibility in how assessments are conducted to accommodate different preferences and comfort levels.
“Talking to somebody you can kind of feel you can build a bit of trust and then talk to them about how you’re feeling. Having a questionnaire I think automatically feels like it’s administration.”
(EP15)
6. Trust
Participants stressed that the effectiveness of assessments largely depended on the rapport they had with their healthcare provider.
They noted that trust built over time could lead to more honest responses and more meaningful discussions about mental health.
Some women also expressed that a trusting relationship with their provider made them more likely to follow up on recommended support or interventions following an assessment.
“I think you do need more formal ways of assessing it, but I think if you have that relationship [with a midwife], when you’re chatting about what’s been going on they’ll pick up if you’re worrying more.”
(SP03)
Insight and Depth
This study is particularly informative as it provides a comprehensive view of women’s experiences with perinatal anxiety assessment across different stages of pregnancy and postpartum.
It reveals that while women generally find these assessments acceptable and beneficial, their experiences are shaped by various factors including the approach to assessment, the healthcare context, and societal attitudes towards mental health.
The research highlights the complex interplay between the need for standardized assessment tools and the desire for personalized, compassionate care.
It suggests that the effectiveness of perinatal anxiety assessments depends not just on the tools used, but on how they are implemented within the broader context of maternal care.
Further research is needed to explore the experiences of more diverse populations and to develop and evaluate assessment approaches that balance standardization with personalization.
The complexity of this topic underscores the need for nuanced, patient-centered approaches to perinatal mental health care.
Strengths
- It included women at different stages of pregnancy and postpartum, providing a comprehensive view of experiences across the perinatal period.
- The sample included women with and without mental health problems, allowing for a range of perspectives.
- The use of semi-structured interviews allowed for in-depth exploration of women’s experiences and views.
- The analysis combined deductive and inductive approaches, ensuring a thorough examination of both expected and emergent themes.
Limitations
- Lack of diversity in the sample: Most participants were white, highly educated, employed, and English-speaking, limiting generalizability to more diverse populations.
- Geographical restriction: The study was conducted only in England and Scotland, potentially limiting its applicability to other healthcare contexts.
- Self-selection bias: Participants volunteered for the study, which may have resulted in a sample more interested in or aware of mental health issues.
Clinical Implications
The results of this study have significant implications for the implementation of perinatal anxiety assessments in healthcare settings. They suggest that:
- Healthcare providers should provide clear information about the purpose and potential outcomes of assessments to increase women’s engagement and honest responses.
- Assessments should be flexible in timing and location, tailored to women’s preferences and circumstances.
- There’s a need to address societal stigma around perinatal mental health to encourage open discussions and help-seeking.
- Integration of assessments with personalized care and continuity of carer could improve women’s experiences and the effectiveness of assessments.
- Training for healthcare providers should emphasize building trust and providing compassionate care alongside conducting standardized assessments.
References
Primary reference
Yuill, C., Sinesi, A., Meades, R., Williams, L. R., Delicate, A., Cheyne, H., … & Walker, J. J. (2024). Women’s experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study. British Journal of Health Psychology. https://doi.org/10.1111/bjhp.12740
Other references
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.
Button, S., Thornton, A., Lee, S., Shakespeare, J., & Ayers, S. (2017). Seeking help for perinatal psychological distress: A meta-synthesis of women’s experiences. British Journal of General Practice, 67(663), e692-e699.
Coates, R., Ayers, S., & de Visser, R. (2014). Women’s experiences of postnatal distress: A qualitative study. BMC Pregnancy and Childbirth, 14, 359.
Fawcett, E., Fairbrother, N., Cox, M., White, I., & Fawcett, J. (2019). The prevalence of anxiety disorders during pregnancy and the postpartum period: A multivariate Bayesian meta-analysis. The Journal of Clinical Psychiatry, 80(4), 18r12527.
Ford, E., Shakespeare, J., Elias, F., & Ayers, S. (2017). Recognition and management of perinatal depression and anxiety by general practitioners: A systematic review. Family Practice, 34(1), 11-19.
Sekhon, M., Cartwright, M., & Francis, J. (2017). Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. BMC Health Services Research, 17(1), 88.
Yapp, E., Howard, L., Kadicheeni, M., Telesia, L., Milgrom, J., & Trevillion, K. (2019). A qualitative study of women’s views on the acceptability of being asked about mental health problems at antenatal booking appointments. Midwifery, 74, 126-133.
Keep Learning
- How might cultural differences affect women’s experiences and views of perinatal anxiety assessment? How could future research address this?
- How might healthcare providers balance the need for efficient, standardized assessments with the desire for personalized, compassionate care?
- What role does societal stigma play in women’s experiences of perinatal anxiety assessment, and how might this be addressed?
- How could the findings of this study inform the development of more effective perinatal mental health services?
- How might the experiences of perinatal anxiety assessment differ for women with pre-existing mental health conditions compared to those without?
- How might the timing of assessments (e.g., during pregnancy vs. postpartum) affect women’s experiences and the effectiveness of the assessments?
