Pre/Postnatal Anxiety

Pre and Postnatal anxiety are terms to describe forms of anxiety which may occur during pregnancy or up to a year post delivery. Feelings of anxiety are incredibly common and normal during pregnancy and through parenthood; with the anticipation of waiting for the baby to be born healthy and well, the fact that there will be another person relying on you to survive and a massive lifestyle change, it is no wonder that mums to be and new mums feel a sense of stepping into the unknown. In order to distinguish the normal emotion that pregnancy induces from clinical anxiety, healthcare professionals must be aware of the signs. Perinatal anxiety affects between 10-15% of all parents who have a baby and is quickly becoming as predominant as perinatal depression within the population of childbearing women. The symptoms of pre/postnatal anxiety are feeling anxious almost constantly, which makes you feel out of control (in pregnancy, this could be fear about your baby’s health and wellbeing or about how you will provide for the baby when he/she is born) panic attacks, fear of leaving the house or doing certain activities, inability to concentrate, irritability, insomnia and digestive problems. Other forms of perinatal anxiety disorder are OCD and PTSD.

Who is at risk of pre/postnatal anxiety?

It is possible that any pregnant woman or new mother could develop perinatal anxiety, whether that be before or after the birth of their child. Father’s can also develop the disorder. There are several factors that could make someone more likely to develop the illness:

  • Suffered perinatal mental illness previously
  • Suffered/are suffering mental health problems, specifically depression
  • Stopped/changed medication during pregnancy
  • a family history of perinatal mental health problems e.g. mother and sister suffered
  • Have experienced a stressful life event recently e.g. bereavement/relationship breakdown
  • Have a ‘perfectionist personality’ or are prone to worrying
  • Having a lack of support
  • Had a previous traumatic event surrounding pregnancy and childbirth e.g. stillbirth
  • Have used illegal drugs

What causes perinatal anxiety?

As with all perinatal mental health disorders, there is no one event or factor that is the cause. A woman’s body undergoes many physiological and psychological changes during pregnancy, childbirth and postnatally to adapt itself for the arrival of a new baby. This can be exacerbated in women who already experience high levels of stress and adrenaline. It is normal for women to feel anxious during pregnancy but if it gets to the point where it is constant and effecting their day to day life, it becomes more of a problem. Throughout childbearing, there is the persistent fear that something may be wrong with the baby, they will not be a good mother or be able to provide what the baby needs. Many mother’s will feel this at some point, but environmental factors can increase the likelihood of the development of an anxiety disorder. For example, if a woman has experienced a previous stillbirth, she will be constantly fearing the same thing may happen again or think that it was her fault, so act in every way possible to stop it from happening (although it was most probably out of her control.) She may not leave the house in fear of pollution, eat a vegan diet to stop the chance of food poisoning, listen to the baby’s heart beat daily and visit the doctor for every minor issue she experiences. This could be an example of generalised anxiety disorder, but she may also have suffered PTSD and encounter flashbacks from the event, or OCD and have strict regimes and compulsions which she thinks will keep the baby in good health.
Other situational factors which may cause the onset of perinatal anxiety are financial difficulties, due to the fear of not being able to give the baby the essentials it needs to survive, a relationship breakdown and having to cope alone, lack of social support and immigrant women, especially if there is a language barrier, because they are separated culturally and socially from the people around them.
This said, any childbearing woman can experience perinatal anxiety, regardless of their physiological and environmental situation.

What treatment is available?

Treatment for perinatal anxiety is similar to what would be on offer for any other anxiety disorder. These include:

  • Cognitive Behavioural Therapy (CBT) to develop coping mechanisms.
  • Counselling enables the sufferer to discuss how they are feeling – this could be especially useful if birth trauma had occurred.
  • Medication can be used under specialist guidance. Some anti-depressant/anxiety medications are not recommended during pregnancy or when breastfeeding due to the adverse effects they could have on the baby, though there are some which are more appropriate.
  • Lifestyle – although lifestyle changes may not ‘cure’ a mental illness, eating healthily, exercising regularly and getting enough sleep can have an impact on the way you are feeling. It can be difficult to do these things whilst pregnant or with a new baby, but these factors can have a psychological impact.
  • Self help – there are a variety of books, online resources and techniques which can help you to relax e.g. mindfulness or hypnosis.

The role of a midwife

It is essential that all health professionals have an awareness of the signs and symptoms to look out for regarding perinatal mental illness, so they can spot them as early as possible and refer to the relevant teams who can ensure that the woman provides a high level of support throughout her pregnancy/postnatal period. During the initial booking appointment, the midwife will ask a series of questions regarding mental health and family history, which can be used as a screening tool to identify people who may be at risk. If the woman discloses that she is already suffering from a mental illness, or has suffered with previous pregnancies, she will automatically be referred to specialists who can work with her to ensure she is safe and provide stability during childbearing. The Royal College of Midwives advises that every maternity unit has a named mental health midwife who is specifically trained in this area.

Early on in pregnancy, midwives should reassure mothers that it is normal to feel nervous, exhausted and stressed during pregnancy but give them information on the signs and symptoms to look out for which could indicate that they are suffering from an anxiety disorder e.g. persistent over a long period and stopping them from doing things in their day to day life. In order for women to feel comfortable in telling their midwife if they feel there is a problem, it is important that there is some continuity of care and a mutual trusting relationship between woman and midwife. This also allows the midwife to identify changes to the woman’s mood over a period of time.

Antenatally, the NICE guidelines state that a nulliparous woman should have 10 appointments and a multiparous appointment. If the woman has a pre-existing mental illness or has a particularly traumatic obstetric history e.g. stillbirth, health professionals should act on an individual basis to ensure that the woman is receiving all the support that she needs. Postnatally, guidelines state that if all is well with the mother and baby, midwives should visit the woman approximately 3 times and discharge at 10 days postpartum and hand over to the health visitor. If a woman is particularly anxious or has a lack of social support, it may be necessary to increase contact time up until 28 days postpartum or until the midwife is sure that the woman is well enough to cope without frequent visits. It is entirely normal for women to feel anxious after they have had their baby; they have just been through a big lifestyle change and now have a baby who is reliant on them. They may not know what they are doing, or if they are doing the right thing and this can cause distress. Midwives have a duty to observe, inform and reassure the mother of ways to keep the baby safe and what to look out for incase of a health emergency. Women will then feel slightly more at ease, knowing what they are doing is safe for the baby and what to do if they think their baby is unwell.

At every appointment, midwives should ask the woman how they are feeling psychologically and observe their behaviour. An anxious mother could be identified by being particularly fidgety, quiet, tearful, has a high blood pressure, or perhaps she is not attending her appointments if she does not want to leave the house. Antenatally, if a woman is worried about the health of her baby, it may be appropriate to listen to the fetal heart (even though NICE guidelines advise this is not routine) or refer for extra scans in cases of previous stillbirth or miscarriage. There are specialist guidelines on the NICE website for women suffering perinatal mental illness which can be referred to.

Lastly, language is important when talking to a mother. Midwives should be sensitive to a woman’s feelings, especially if she has been through traumatic events previously. It is not appropriate to tell a woman ‘not to worry’ or ‘everything will be ok’ because this can lead to false reassurance. It would be more appropriate to say, ‘at this moment, your baby is well and we can pick up any changes to his/her health and act accordingly IF problems arose. You are doing brilliantly, I know this is hard for you, but we are here to support you.’ Acting in an open and approachable manner will enable women to discuss subjects such as mental health with the midwife, helping to reduce possible risk factors as soon as you are aware.

What other support can be given to women?

The PANDAS Foundation (Pre And postNatal Depression Advice and Support) offer a variety of support services to women and their families who are suffering from all perinatal mental illnesses. These include: a helpline, open 7 days a week, 9am-8pm; email support, a closed facebook group, social media pages and local support groups. All details can be found on the PANDAS website along with a variety of useful information on perinatal mental illness.
Our services are provided by volunteers, the majority have lived experience of perinatal mental illness. They can provide practical advice and a listening ear for those in need, as well as advice to healthcare professionals on the most appropriate ways to support those in their care. We offer an advocacy service for those who do not feel they can effectively communicate with their primary care givers, run by a trained safeguarding officer.

References

1. Royal College of Psychiatrists, Green, L. and Thachil, A. (2012) Mental health in pregnancy. Available at: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalhealthinpregnancy.aspx (Accessed: 21 November 2016).

2. Fairbrother, N., Janssen, P., Antony, M., Tucker, E. and Young, A. (2016) ‘Perinatal anxiety disorder prevalence and incidence’, Journal of Affective Disorders, 200, pp. 148–155.

3. Tommy’s (2016) Anxiety and panic attacks. Available at: https://www.tommys.org/pregnancy-information/im-pregnant/mental-wellbeing/specific-mental-health-conditions/anxiety-and (Accessed: 25 November 2016).

4. Darby, S. (2016) What are the risk factors for Postpartum anxiety? 3 to keep in mind. Available at: https://www.romper.com/p/what-are-the-risk-factors-for-postpartum-anxiety-3-to-keep-in-mind-18530 (Accessed: 25 November 2016).

5. Blackmore, E., Cote-Arsenault, D., Tang, W. et al. Previous Prenatal Loss as a Predictor of Perinatal Depression and Anxiety. British Journal of Psychiatry. 2011. 198(5):373-378.

6. Robertson, E., Grace, S., Wallington, T. and Stewart, D. (2004) ‘Antenatal risk factors for postpartum depression: a synthesis of recent literature’, General Hospital Psychiatry, 26(4), pp. 289–295.

7. MIND (2013b) Anxiety treatments. Available at: http://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/anxiety-treatments/#.WDgR3eaLTIU (Accessed: 25 November 2016).

8. Royal College of Midwives (2013). Specialist Mental Health Midwives: What they do and why they matter. Available at: https://www.rcm.org.uk/sites/default/files/MMHA%20SMHMs%20Nov%2013.pdf (Accessed 21st November 2016)

9. National Institute for Health and Care Excellence (NICE), 2008. Antenatal Care for Uncomplicated Pregnancies. London: NICE.

10. National Institute for Health and Care Excellence (NICE), 2014. Antenatal and Postnatal Mental Health. London: NICE.

With thanks

In partnership with The PANDAS Foundation. To find out more visit their website which contains a wealth of information for patients, carers and professionals.