Identifying acceptable and effective methods of assessing perinatal anxiety: the MAP study

Anxiety is a common mental illness that can occur during and after pregnancy, which is associated with an increased risk of adverse outcomes for women and their infants. Despite this, there is no consensus on the best method of assessing anxiety.

The methods of assessing perinatal anxiety (MAP) study aimed to identify the most acceptable, effective and feasible method for assessing anxiety in pregnancy and after birth.

The MAP study had four work packages: a qualitative and cognitive interview study (work package 1); a prospective longitudinal cohort study of women during pregnancy (early, mid- and late pregnancy) and post partum, with nested diagnostic interviews (work package 2) and implementation case studies (work package 3). Secondary analysis of cohort data was commissioned as an add-on project to examine the impact of socioeconomic deprivation on perinatal anxiety (work package 4). The MAP study evaluated four assessment measures based on clinical criteria and research evidence: the General Anxiety Disorder Questionnaire, 2-item, or 7-item version scale, Whooley questions, Stirling Antenatal Anxiety Scale and Clinical Outcomes in Routine Evaluation - 10 item version scale.

Qualitative and cognitive interviews (work package 1) were conducted with 41 pregnant and postpartum women, recruited through patient and public involvement representative organisations and social media. The MAP cohort (work package 2) included 2243 women recruited through 12 National Health Service Trusts in England and 5 National Health Service Boards in Scotland. Diagnostic interviews were conducted with a consecutive subsample of 403 participants. Implementation case studies (work package 3) were conducted with two National Health Service sites in England and one in Scotland.

Routine assessment of perinatal anxiety was acceptable to women and was viewed positively, although this was qualified by the extent to which the process was informed and personalised. Results from cognitive interviews found that all measures were acceptable and easy to use. Diagnostic accuracy was greatest for the Stirling Antenatal Anxiety Scale and Clinical Outcomes in Routine Evaluation - 10 item version. Increased anxiety on all measures was associated with greater difficulties with daily living, poorer quality of life and participants wanting treatment. Early pregnancy (i.e. the first trimester) was the optimal time for identifying participants with anxiety disorders who wanted treatment. Two measures met criteria for implementation: the Stirling Antenatal Anxiety Scale and the Clinical Outcomes in Routine Evaluation - 10 item version. The Stirling Antenatal Anxiety Scale was preferred by stakeholders (41 women and 55 health professionals), so it was implemented. Acceptability to health professionals (N = 27) of routine assessment using the Stirling Antenatal Anxiety Scale was good. Potential barriers to conducting assessments informed the development of a guide to implementation. The prevalence of anxiety disorders was 19.9% (confidence interval 16.1 to 24.1), with highest prevalence in early pregnancy (25.5%, confidence interval 17.4 to 35.1). A complex relationship was found between regional deprivation and perinatal anxiety, with regional differences in prevalence being explained by sociodemographic composition.

The MAP cohort had a greater ethnic diversity than the general population, but participants were highly educated. The study evaluated four measures, so it could not determine whether other measures are more effective. The qualitative and observational research design means causality could not be inferred.

The MAP study found that routine assessment of perinatal anxiety is acceptable to women and is feasible to implement in National Health Service services. The Stirling Antenatal Anxiety Scale and Clinical Outcomes in Routine Evaluation - 10 item version were most effective at identifying women with perinatal anxiety disorders who wanted treatment.

Further research is needed to determine whether implementing routine assessment of perinatal anxiety results in improved outcomes for women and children.

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/16.