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Improving Understanding and Detection of Postpartum Anxiety

Hoberg, Mary G and Demirci, Jill Radtke and Sereika, SM and Levine, MD and DeVito Dabbs, Annette J (2022) Improving Understanding and Detection of Postpartum Anxiety. Doctoral Dissertation, University of Pittsburgh. (Unpublished)

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Background: Maternal mental health conditions are the most common complications in the postpartum period (Luca et al., 2019; US Preventive Services Task Force et al., 2019). Recognition that postpartum anxiety (PPA), anxiety during the post-partum period, is more prevalent than postpartum depression (PPD), and its significant impacts on maternal and infant outcomes, has raised interest in improving its detection (Accortt & Wong, 2017; Fairbrother et al., 2016; Fawcett et al., 2019). Yet, detection challenges remain including lack of diagnostic criteria for PPA (Jordan & Minikel, 2019; Zappas et al., 2020), difficulties differentiating between levels of anxiety (e.g., adaptive worry after childbirth, generalized anxiety, and postpartum-specific anxiety) (Howard & Khalifeh, 2020; Lorenzo, 2022; Zappas et al., 2020), and lack of consensus for a PPA-specific screening tool (Thorsness et al., 2018; Zappas et al., 2020). A better understanding of the course and temporal patterns of PPA, such as severity and influencing factors over time, is warranted to improve detection of PPA. Also, more descriptive research is needed to expand understanding of anxiety in postpartum contexts which may help to further delineate postpartum-specific anxiety from generalized anxiety and aid in detection and clinical management of the condition.
Purpose: To describe the prevalence, stability, trends, and context of anxiety from the 3rd trimester of pregnancy (e.g., 27 to 40 weeks of pregnancy) to eight-weeks postpartum using multiple measurement modalities. Modalities included questionnaires to assess mood and ecological momentary assessments (mEMA) asking participants to rate daily anxiety levels and respond to open-ended mEMA questions guided by the Theory of Becoming a Mother (Mercer, 2004). Qualitative findings were compared between those with and without anxiety at eight-weeks postpartum and integrated with quantitative findings in a narrative synthesis.
Sample and Setting: A convenience sample of 73 birthing people who planned to give birth to their infants at a large academic tertiary center in the Mid-Atlantic U.S. were enrolled. Study activities were performed remotely between August 2021 to March 2022.
Methods: The study used a prospective, mixed-methods, cohort design for the purpose of development (i.e., mEMA daily anxiety ratings were used to develop a stratified sampling plan for the qualitative mEMA responses), and for the purpose of expansion (i.e., anxiety questionnaires were used to develop categories of participants by presence of anxiety). The State Trait Anxiety Inventory, State Scale (STAI-S) and Postpartum Specific Anxiety Scale (PSAS) were administered at baseline (3rd trimester, STAI-S only), one-, and eight-weeks postpartum. mEMA prompts were sent to participants to rate their daily anxiety on a scale of 0, “not at all” to 10, “very much so” and respond to open-ended questions regarding perceived stress, social support, role adjustment, environment, and source of daily anxiety. Established cut-off scores for anxiety on the STAI-S and PSAS were used to determine anxiety prevalence at each study timepoint using descriptive statistics. Stability of the STAI-S and PSAS was evaluated with a dependent samples t-test and repeated measures analysis of variance. Linear mixed modeling was used to evaluate trends in individuals’ daily anxiety ratings. The mode and variance of daily anxiety ratings for participants who returned ≥ 50% of mEMA prompts were used to stratify participants into four groups, from which 50% of the cases in each group were randomly selected for subsequent qualitative analysis (N = 34). Qualitative data were analyzed using qualitative descriptive methods and a theory-driven coding framework. Participants’ responses were organized into thematic-categories and major concepts. Eight-week STAI-S and PSAS scores were used to categorize participants by presence of anxiety based on established cut-off scores for anxiety (> 40 and > 112), respectively. Thematic-categories between anxiety classifications were compared using matrices, a joint display, and narrative synthesis to expand understanding.
Findings: In our sample of mostly white (81%), partnered (90.4%), and highly educated (≥ graduate degree, 75%) people, mean STAI-S anxiety scores were significantly higher [F(1.85, 129.18) = 4.305, p = 0.018] at one week postpartum (36.4  11.0) than at eight-weeks postpartum (33.4  9.6). Mean PSAS scores were significantly higher [ t(70) = 3.047, p = 0.003] at eight-weeks postpartum (93.9  20.7) than at one-week (88.6  19.6). The proportion of the sample above the cut-off for anxiety on the STAI-S (> 40) in descending order was greatest at one-week postpartum (28.8%), lower at eight weeks (23.9%), and lowest at baseline (3rd pregnancy trimester) (21.9%). The proportion above the cut-off for anxiety on the PSAS (> 112) in descending order was greatest at eight-weeks (21.1%) and lowest at one-week postpartum (12.3%). The proportion who met anxiety thresholds on either the STAI-S or PSAS was greater at eight-weeks (35.2%) than one-week postpartum (31.5%). Only 33% of the sample’s responses for daily anxiety ratings between one- to eight-weeks postpartum (968/2936) indicated no level of daily anxiety (e.g., 0). Aggregated mean daily anxiety ratings were highest at two-weeks, declined and stabilized, then trended upward toward week eight postpartum, t(65.56) = 2.15, p = 0.036, 95% CI, [0.000034, 000944]. Individuals who met cut-offs for anxiety at eight-weeks postpartum described feeling more overwhelmed, having less support, experiencing more relationship conflict, difficulty adjusting to maternal roles, and having less positive environmental influences than those without anxiety. Further, there were qualitative differences between participants with anxiety per the STAI-S and anxiety per the PSAS. Specifically, participants with anxiety per the PSAS alternated between feeling able to “manage” their responsibilities and “overwhelmed” by their responsibilities over the study period. Alternatively, participants with anxiety per the STAI-S consistently reported feeling overwhelmed. Regarding support, participants with anxiety per the PSAS reported task-related support in the early weeks postpartum that declined as the time from birth lengthened, while participants with anxiety per the STAI-S consistently described lack of support. Further, individuals with anxiety per the PSAS reported relationship conflict more often and described daily sources of anxiety (e.g., infant-related concerns and return to the workplace) that were different than daily sources of anxiety per the STAI (e.g., self-health, finances, and partner work/travel). Participants with anxiety based on either questionnaire shared similar response patterns for perceived stress, social support, and role adjustment. Regarding environmental influences, participants with anxiety per the STAI-S often mentioned the negative influences of fatigue, deficient support systems, infant temperaments, and/or other children’s needs. Alternatively, participants with anxiety per the PSAS reported similarly negative environmental influences from relationship conflict and deficient support as those with anxiety per the STAI-S or both the STAI-S and PSAS, but also recounted more positive influences from socialization opportunities that the other categories of anxiety did.
Conclusions: Our study found that mean anxiety scores decreased from one- to eight-weeks postpartum per the STAI-S, but increased from one- to eight-weeks postpartum per the PSAS. These findings suggest postpartum-specific anxiety may worsen as the time from birth lengthens. Our findings also corroborate reportedly high anxiety prevalence at eight-weeks postpartum, where per the STAI-S, 23.9% of the sample had anxiety and per the PSAS, 21%. Although more participants met the cut-off for anxiety per the STAI-S at eight-weeks postpartum, consideration should be given to the potential that STAI-S scores were falsely inflated, as instrument items were developed to measure somatic symptoms in general and not postpartum populations (Infante-Gil et al., 2022; Meades & Ayers, 2011; Spielberger et al., 1983). Daily anxiety ratings showed that anxiety is a shared experience across the postpartum; for most peaking at two-weeks, declining and stabilizing, then trending upward toward week eight postpartum. However, for some, daily anxiety ratings increase more dramatically as the time from birth lengthens. Responses to theory-driven mEMA questions offered qualitative validation for existing assumptions regarding relationships between high perceived stress, low social support, relationship conflict, and maternal role adjustment and provide possible new directions for anxiety detection strategies (e.g., assessing presence of relationship conflict, negative environmental influences, or sources of anxiety). Future studies should explore the course and stability of anxiety beyond eight-weeks postpartum, the influence of other participant characteristics on anxiety (e.g., demographics, obstetrical history, presence of pregnancy or birth-related complication), and the relationship between postpartum-specific anxiety and generalized anxiety in postpartum populations.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Hoberg, Mary Gmgh30@pitt.edumgh30
Demirci, Jill Radtkejvr5@pitt.eduJVR5
Sereika, SMssereika@pitt.eduSSEREIKA
Levine, MDmlevine@pitt.eduMLEVINE
DeVito Dabbs, Annette Jajdst42@pitt.eduAJDST420000-0003-3325-435X
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Committee ChairDeVito Dabbs, Annette Jajdst42@pitt.eduajdst42
Committee MemberDemirci, Jill Rjvr5@pitt.edujvr5
Committee MemberSereika, Susanssereika@pitt.edussereika
Committee MemberLevine, Michele DMLEVINE@pitt.eduMLEVINE
Date: 10 August 2022
Date Type: Publication
Defense Date: 14 July 2022
Approval Date: 10 August 2022
Submission Date: 29 July 2022
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Number of Pages: 191
Institution: University of Pittsburgh
Schools and Programs: School of Nursing > Nursing
Degree: PhD - Doctor of Philosophy
Thesis Type: Doctoral Dissertation
Refereed: Yes
Uncontrolled Keywords: postpartum anxiety; maternal mental health; perinatal
Date Deposited: 10 Aug 2022 17:56
Last Modified: 10 Aug 2022 17:56


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