Women who experience anxiety while pregnant are more likely to give birth earlier 

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Women who experience anxiety about their pregnancies give birth earlier on average than those who don’t, according to research published by the American Psychological Association.

The study, which examined the relationship between pregnancy length and different measures of anxiety, could help doctors understand when and how best to screen for anxiety during pregnancy to help prevent preterm birth.

“Anxiety about a current pregnancy is a potent psychosocial state that may affect birth outcomes,” said lead study author Christine Dunkel Schetter, PhD, of the University of California Los Angeles.

“These days, depressive symptoms are assessed in many clinic settings around the world to prevent complications of postpartum depression for mothers and children. This and other studies suggest that we should also be assessing anxiety in pregnant women.”

The study was published in the journal Health Psychology.

Previous research has found that up to one in four pregnant women has clinically elevated anxiety symptoms and that anxiety can be a risk factor for preterm birth, or birth before 37 weeks of pregnancy.

However, those studies have used a variety of measures of anxiety and have looked at both general anxiety and pregnancy-specific anxiety, which includes worries about childbirth, parenting and the baby’s health.

Researchers have also measured anxiety at different points in pregnancy, from early to late pregnancy and most often in the second trimester.

To sort out these various effects of timing and anxiety type, the researchers examined data from a diverse sample of 196 pregnant women in Denver and Los Angeles who took part in the Healthy Babies Before Birth study. Forty-five percent of the women identified as non-Hispanic white, 36% as Hispanic white, 10% as Asian and 9% as Black or African American.

The researchers administered four different anxiety scales to the women, in both the first and the third trimesters of their pregnancies. One was a five-question screener for general anxiety and three were specific to pregnancy: a 10-question and a four-question scale of pregnancy-related anxiety, and a nine-question assessment of a broader range of pregnancy-related stressors, such as medical care and worries about taking care of a newborn.

The researchers found that participants’ scores on all three scales of pregnancy-related anxiety were interrelated, suggesting that the scales measure the same underlying thing.

They also found that pregnancy-related anxiety in the third trimester was most strongly associated with earlier births. However, general anxiety in the first trimester also contributed to risk for early birth.

One possibility, according to the researchers, is that general anxiety early in pregnancy could predispose women to be anxious later in pregnancy about such issues as medical risks, the baby, labor and delivery, and parenting.

The results held even when adjusted for the actual medical risk of the women’s pregnancies.

“Although not all women who begin pregnancy with general anxiety symptoms will later experience pregnancy-specific anxiety, our results suggest that women who do follow this progression are likely to be especially at risk for earlier delivery,” Dunkel Schetter said.

The results suggest that doctors should screen women for general anxiety early in pregnancy, she added, just as they commonly screen for depression, and that women who score high could be monitored for increases in anxiety and possible intervention later in pregnancy.

Further research should continue to explore reasons that pregnancy anxiety is linked to birth timing, including stress-related neuroendocrine changes, inflammation and health behaviors, according to Dunkel Schetter.

“Increasing precision in our understanding of both the risks and mechanisms of the effects of pregnancy anxiety on gestational length can improve our ability to develop, test and implement interventions to address the pressing public health issue of preterm birth,” she said.


Preterm birth is commonly defined as birth before 37 weeks’ gestation [1]. The global incidence of preterm birth is estimated at 15 million per year with an average of 11.8% of births being preterm in low-income countries [2]. Pakistan has a particularly high burden of preterm birth (18.9%) [3], which exceeds those of other countries in the region including India (15%), Bangladesh (11%), and Indonesia (15.5%) [4–6]. As such, preterm birth is a global public health concern since it contributes directly to neonatal mortality and childhood morbidity [7]. Thus, addressing preterm birth is critical to addressing neonatal and child mortality and morbidity, particularly in resource-poor settings.

Pregnancy-related anxiety, antenatal depressive symptoms, and perceived stress have been identified as risk factors for adverse maternal-infant birth outcomes [8–13]. Over the last two decades, many studies, including a meta-analysis [14] have shown that higher pregnancy-related anxiety is associated with preterm birth. However, the nuances in this relationship remain to be elucidated. While Dole and colleagues [15] found that women experiencing medium and high counts of pregnancy-related anxiety items showed an increased risk of preterm birth (RR = 1.5, 95% CI 1.1–2.1; RR = 2.1, 95% CI 1.5–3.0), Orr and colleagues [16] found this to be true of high counts of pregnancy-related anxiety only (OR 1.50–2.73, 95% CI 1.01–7.27).

Similarly, Kramer and colleagues [17] were able to demonstrate that pregnancy-related anxiety had a dose-response relationship with spontaneous preterm birth (OR = 1.8, 95% CI 1.3–2.4). Although both Rauchfuss and Maier [18] and Tomfohr-Madsen and colleagues [19] found that pregnancy-related anxiety was positively associated with preterm birth (OR 1.44, 95% CI 1.02–2.05; OR 8.54), Tomfohr-Madsen and colleagues [19] found that shorter sleep duration had a moderating role in the relationship between pregnancy anxiety and birth outcomes. Further research is required to understand the relationship between the various components of the pregnancy-related anxiety scale and preterm birth in different settings.

Conversely, antenatal depressive symptoms were associated with preterm birth in many [8, 20–25], but not all [26–28] studies. For instance, Liu and colleagues [29] found that mothers who experienced both new and recurrent depression during pregnancy were more likely to give birth early (OR = 1.34, 95% CI 1.22–1.46; OR = 1.42, 95% CI 1.32–1.53). In their population-based study, Li and colleagues [21] found that women who experienced increasing severity of depression were more likely to give birth early, suggesting a potential dose-response relationship. However, Fransson and colleagues [20] concluded that even moderate levels of depressive symptoms significantly elevated the risk for preterm birth (OR = 3.14, 95% CI 1.37–7.19).

Furthermore, Grote and colleagues [30] found that while women with depression during pregnancy are at increased risk for experiencing a preterm birth, the magnitude of the effect size varies depending on how it is measured, country of residence, and socioeconomic status. Conversely, not all of the available studies have found similar relationships. For example, Gavin and colleagues [26] found no association between depressive symptoms and preterm birth respectively (OR = 1.1, 95% CI 0.6–1.9). The literature is also inconsistent with respect to the relationship between perceived stress and preterm birth. Dole and colleagues [15] and Seravalli and colleagues [31] have demonstrated a trending towards an association between perceived stress and preterm birth (RR = 1.3, 95% CI 0.9–1.8; OR = 1.49, 95% CI 1.00–2.23 [14, 28, 29] while Krabbendam and colleagues [32] and Sealy-Jefferson and colleagues [33] have identified no effect (OR = 1.10, 95% CI 0.77–1.59; PR = 1.14, 95% CI 0.97–1.34). Therefore, a more complex relationship may exist between antenatal depressive symptoms, pregnancy-related anxiety, perceived stress, and preterm birth.

The inconsistencies in the literature may be due to a failure to consider changes in pregnancy-related anxiety and antenatal depressive symptoms over the course of pregnancy, and its association to preterm birth. As such, changes in measures of psychosocial distress may be more informative than assessments at a single time point in understanding the dynamic relationship between perinatal distress and adverse pregnancy outcomes. A few authors have found that there may be a blunting of psychological and biological responses to perceived stress late in the second trimester, which may protect the mother and the fetus from adverse health outcomes [13, 34, 35]. Pregnant women who did not perceive a decrease in perceptions of stress levels over the course of pregnancy or dampening of biological responses into the late second trimester, could be at increased risk of preterm birth [34, 36].

A few studies have examined the relationship between psychosocial distress and preterm birth by considering the dynamic nature of pregnancy. These studies have repeatedly assessed measures of pregnancy-related anxiety [13, 37, 38] and antenatal depressive symptoms [27, 39–43] in the second and third trimester. Doktorchik and colleagues [39] studied the relationship between changes in anxiety and depression between 17 to 24 weeks’ of gestation and 32 to 36 weeks’ of gestation with preterm birth.

They found that women who experienced an increase in anxiety scores had 170% higher odds of preterm birth compared to those who had a decrease in anxiety scores. Other studies have also repeatedly assessed measures of pregnancy-related anxiety [13, 27, 37, 38] and antenatal depressive symptoms [40, 42] in the second and third trimester. Doktorchik and colleagues [39] found a similar pattern with anxiety, indicating that women who experience an increase with anxiety scores over the course of pregnancy were at greater risk for preterm birth in Canada.

The same pattern did not hold true for antenatal depressive symptoms. While the overall risk for prematurity increased if women experienced more than one psychological disorder—pregnancy-related anxiety, antenatal depressive symptoms, and perceived stress [41], Doktorchik and colleagues [39] found that a co-occurring increase in anxiety and depression scores did not increase the risk of preterm birth, and perceived stress did not modify any of these relationships.

It is also the case that empirical research critically examining psychosocial processes predominantly originates from high-income countries [44–46] and fails to recognize the complex multisystem interactions in the pathways to adverse health outcomes for both mother and fetus over the course of pregnancy [47]. The viewpoint of a life course suggests that early life experiences and repetitive stressors over an individual’s life will lead over time to “wear and tear” on the brain and body, undermining psychosocial and biological responses to stress [48, 49]. These biopsychological responses in early life manifest later as psychological health issues during adulthood and pregnancy thereby contributing to preterm birth [50]. On the contrary, our recent work does not support the relationship between adverse life experiences and preterm birth in the Pakistani context [51].

In low- and middle-income countries, pregnant women face disparities in health determinants (e.g. social, cultural, economic, and political contexts) that can change perceptions of psychosocial distress and biological responses, thereby differentially affecting psychological and biological response patterns during pregnancy [47]. At the societal level, women in Pakistan are more vulnerable to adverse events and life course alterations [47]. Individual situations such as maternal employment and support systems are other notable factors influencing maternal psychological health. For instance, when fathers are not involved during the pregnancy the risk of preterm birth was found to be 21% higher (OR = 1.21, 95% CI: 1.01–1.45) [52, 53].

Women working strenuous jobs are two times more likely to deliver preterm babies as compared to those performing management tasks and sedentary work [53, 54]. Correspondingly, more than 50% of women with unplanned pregnancies experience higher stress levels opposed to women with planned pregnancies [55]. Women experiencing neighborhood disadvantage in terms of physical disorder in the neighborhood and racism, particularly black women, were also two times more likely to deliver preterm (OR = 2.64; OR = 2.16, 95% CI 1.39–3.35) [53, 56, 57].

The interplay between the multitude of risk factors on preterm birth has not been fully explored, particularly in low- and middle-income countries where likelihood of adverse health outcomes is far greater [58]. Therefore, exploration of the relationship between antenatal depressive symptoms, pregnancy-related anxiety, perceived stress, and preterm birth is needed to understand the possible contribution on birth outcomes.

referencelink :https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250982


reference link :Original Research: The findings will appear in Health Psychology

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