Measures of anxiety, depression and stress in the antenatal and perinatal period following a stillbirth or neonatal death: a multicentre cohort study

Abstract

Background The grief associated with the death of a baby is enduring, however most women embark on another pregnancy, many in less than a year following their loss. Symptoms of anxiety and depression are reported to be increased in pregnancies after perinatal death, although effect on maternal stress is less clear. Variation between individual studies may result from differences in gestation at sampling, the questionnaire used and the type of antecedent perinatal death. We aimed to describe quantitative measures of anxiety, depression, stress and quality of life at different timepoints in pregnancies after perinatal death and in the early postnatal period. Methods Women recruited from three sites in the North-West of England. Women were asked to participate if a previous pregnancy had ended in a perinatal death. Participants completed validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score) and health status (EQ-5D-5L™ and EQ5D-Visual Analogue Scale) at three time points, approximately 15 weeks’ and 32 weeks’ gestation and 6 weeks postnatally. A sample of hair was taken at approximately 36 weeks’ gestation for measurement of hair cortisol in a subgroup of women. The hair sample was divided into samples from each trimester and cortisol measured by ELISA. Results In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks’ gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p<0.001). Hair cortisol levels fell in a similar profile to anxiety and depression symptoms (p<0.05). In contrast, the median EQ-5D index, measuring health status was 0.768 at 15 weeks’ gestation (Interquartile range (IQR) 0.684-0.879), 0.696 at 32 weeks’ (IQR 0.637-0.768) and 0.89 (0.760-1.00) at 6 weeks postnatal. There was a negative relationship between EPDS and perceived health status. Conclusions This study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels in women in pregnancies after a stillbirth or neonatal death which decrease as pregnancy progresses. Further studies are needed to determine optimal care for women to address these negative psychological consequences.

Women’s experiences of a pregnancy whilst attending a specialist antenatal service for pregnancies after stillbirth or neonatal death: a qualitative interview study

“…Semi-structured interviews were conducted with a sub-group of women who volunteered to take part in an interview after being recruited to a larger quantitative study [3]. An interview topic guide designed by the research team, with input from a patient panel, guided the interviews through four sections: (i) history leading to care pathway, (ii) the experience of coping with new pregnancy after loss, (iii) support received in pregnancy, and (iv) advice for others.…”

“…Pregnancy following a prior stillbirth or neonatal death is associated with a series of emotional and psychological challenges for women and their families; these pregnancies are characterised by increased anxiety, depression, perceived stress and decreased confidence that the pregnancy will have a healthy outcome [1][2][3]. Likewise, many mothers and fathers report the loss of 'normal' positive feelings that they expected, such as joy [2].…”

Better maternity care pathways in pregnancies after stillbirth or neonatal death: a feasibility study

“…Despite prioritisation of research by both health professionals and parents [ 33 ], few studies have explored development or evaluation of new antenatal care pathways or services [ 34 ]. The current study did not aim to assess the impact of the intervention on outcomes; however, the psychological and health status measures reflect previous studies suggesting negative psychological state decreasing as pregnancy progresses [ 5 ]. The study intervention was co-designed for maximum flexibility and practicality of implementation alongside existing services.…”

“…The death of a baby before, during or soon after birth is acknowledged as amongst the most traumatic life-events for parents [2]. Most women will conceive again, and subsequent pregnancies are often characterised by increased anxiety, stress and emotional vulnerability, particularly when inter-pregnancy intervals are short [3][4][5]. Psychological distress in pregnancy is associated with adverse outcomes and after perinatal death often persists beyond the birth of a healthy child, risking disrupted maternalinfant attachment and parenting difficulties [6].…”

Development and Psychometric Validation of the Perinatal Bereavement Care Competence Scale for Midwives

“…Perinatal loss is a highly painful event for parents and families [1]. Most bereaved parents suffer from devastating psychological and emotional symptoms including grief, depression, anxiety, selfblame, and post-traumatic stress, which even cause adverse effects for subsequent pregnancies [2,3]. Appropriate bereavement care provided by hospital staffs is essential for helping parents cope with perinatal loss and reducing its negative impact [4,5].…”