What questions should we ask about anxiety in pregnancy and after birth?

Rose Coates, Louise Williams, Andrea Sinesi & Susan Ayers, The MAP Research Team at City University of London and the University of Stirling

NCT practitioners, volunteers and peer supporters will be aware that mental health in pregnancy and after birth is very important for the mother, her partner, and their baby. Unfortunately, however, an estimated 10-20% of women will experience a mental health issue such as anxiety or depression, in pregnancy or within the first year of having their baby. This not only negatively impacts on the mother and those close to her, but has also been linked with poorer future outcomes for the children, such as behavioural, social and emotional difficulties. It is therefore important that mental health issues are identified as early as possible to ensure that further treatment can be provided if necessary.

Whilst some women may tell their GP, midwife or health visitor that they are experiencing mental health difficulties, how should we go about identifying those women who don’t disclose how they are feeling?

How are mental health problems currently identified?

The National Institute for Clinical Excellence (NICE) has long recommended that GPs, midwives, health visitors and other healthcare professionals who meet with pregnant women or women who have just had a baby, consider asking two questions to identify those experiencing symptoms of depression. The questions are ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ and ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’ If a woman responds with a ‘yes’ to either question, the next step is to ask further more detailed questions or refer on to the GP or a mental health professional if a severe problem is suspected (NICE, 2018).

NICE base their recommendations on reviews of the research evidence base worldwide, and support for these questions identifying depression in pregnancy and after birth is provided (NHS, 2018). However, it is currently unknown whether these questions might also work to identify other mental health issues such as anxiety. It is unlikely that one set of questions will identify everyone with depression, and it is also important that questions do not falsely identify women who actually are not depressed. Additionally, the questions are only likely to work when healthcare professionals have been properly trained on how to ask the questions sensitively. Healthcare professionals also need enough time to ask questions as part of a conversation, and clear referral and care pathways. The NCT’s Hidden Half campaign is relevant to this. The campaign is demanding an improvement to the 6-week postnatal check up to enable GPs (or other healthcare professionals) to spend more time with each woman and therefore enable identification of mental health issues at their last routine maternity appointment.

What about anxiety?

In addition to depression, anxiety is commonly experienced in pregnancy and after having a baby. Some worries and anxieties, especially during pregnancy, are relatively common and are experienced by a considerable number of women. However, a substantial minority of women experience anxiety symptoms that are more intense or persistent, and that might thus require clinical attention. Anxiety can be experienced in many ways and specific disorders include generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, phobias, post-traumatic stress disorder and social anxiety disorder. Women may not have a disorder, but may still be troubled by symptoms of anxiety, which affect both the body and the mind. These include excessive worrying, having a sense of dread, feeling restless or unable to relax, faster breathing and problems sleeping amongst others (MIND, 2017).

Do healthcare professionals ask about anxiety?

In 2014 NICE added a recommendation to their antenatal and postnatal mental health guideline that healthcare professionals consider asking two questions about anxiety (NICE, 2018). The questions are: ‘Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ and ‘Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?’ An answer of ‘Not at all’ scores 0; ‘Several days’ scores 1; ‘More than half the days’ scores 2; ‘Nearly every day’ scores 3. If a woman has a total score of 3 or more, the next step is to ask further questions or refer the woman to her GP or to a mental health professional for suspected severe anxiety.

The difficulty with this recommendation is that there was very little research available to allow NICE to make any definite conclusions about the most effective questions to ask. In fact there was so little research with pregnant women and those who had recently had a baby, that the guidelines were based on research with other (not pregnant) populations. Essentially, we don’t know whether these 2 questions work well to identify pregnant or postnatal women experiencing problematic anxiety symptoms. Neither do we know what women think about these questions, or about healthcare professionals’ experiences of using these questions.

The MAP Project

At City, University of London and the University of Stirling, we are working in collaboration with the NCT and Maternal Mental Health Change Agents to assess which questions work best to identify anxiety in pregnancy and soon after having a baby. The study, Methods of Assessing Perinatal Anxiety (MAP) is comparing four different questionnaires, including the two sets of questions mentioned above. The questionnaires were selected based on a review of the evidence. The research incorporates three projects:

1. The first project started in June and aims to find out which questionnaire is most acceptable to women. We are interviewing some women who have experienced anxiety in pregnancy, and some women who have not. We are asking them about their views on the four questionnaires along with their experiences of being asked about anxiety during pregnancy and after having a baby.

2. The second project will find out which of the questionnaires best identifies women who need treatment by comparing questionnaire responses with a longer interview asking about mental health. We will ask women to complete questionnaires at three time points during pregnancy (12 weeks, 22 weeks and 31 weeks) and once after birth (6 weeks postpartum). These discrete time points should also enable us to find out when is the most effective time to ask women about anxiety.

3. The results of the first two projects will inform the use of the questionnaire to be used in this third project. At selected health services in England and Scotland we will ask healthcare professionals what their experiences are of this questionnaire, and how acceptable and practical it is for them to use it.

Who decided to do this research?

We developed this research programme with help and guidance from a group of experts. These are women who have experience of perinatal mental illness, midwives, mental health professionals, the NCT and Maternal Mental Health Change Agents. This group identified the assessment of perinatal anxiety as a priority problem and will continue to work with us through the project to ensure its relevance to women and the NHS. The research team includes psychologists, midwives, obstetricians, health visitors, GPs, nurses and mental health professionals.

What can I do?

If you would like to help with the MAP project, please let pregnant women (and women who have had a baby up to 6 weeks ago) know about our project. This will give them the opportunity to participate. We are recruiting women who do have symptoms of mental health issues, and women who do not. Please feel free to show them this article, our website or a briefer explanation can be found in our advert [below] If you would like hard copies of the advert to hand out at your classes or drop-ins, or have any other questions relating to this research please contact map@city.ac.uk.

If you think that a pregnant woman or someone who has recently had a baby is experiencing anxiety, we encourage you to support them to talk to their GP, midwife, health visitor, or other healthcare professional.

This project is funded by the National Institute for Health Research (NIHR), HS&DR Programme (17/105/16). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

References and Resources

Methods of Assessing Perinatal Anxiety (MAP) Study website: https://blogs.city.ac.uk/map/about-us/

MIND (2017) Anxiety and panic attacks: https://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/anxiety-symptoms/#.XS8LAJNKg2w

PANDAS Foundation, Pre- and Post-natal depression advice and support. www.pandasfoundation.org.uk

Anxiety UK, provides information and support for those living with anxiety and anxiety-depression: www.anxietyuk.org.uk

NICE (2018) Antenatal and postnatal mental health: clinical management and service guidance, Clinical guideline [CG192]: https://www.nice.org.uk/guidance/cg192/chapter/1-Recommendations#recognising-mental-health-problems-in-pregnancy-and-the-postnatal-period-and-referral-2

NCT How you might be feeling in pregnancy: https://www.nct.org.uk/pregnancy/how-you-might-be-feeling

NHS (2018). Researchers call for routine mental health screening during pregnancy: https://www.nhs.uk/news/pregnancy-and-child/researchers-call-routine-mental-health-screening-during-pregnancy/

Making an antenatal course useful for dads

Jenny Barrett, NCT antenatal practitioner

It might sound a bit obvious, but half of our clients in antenatal courses are not pregnant and, in most cases, they are dads. Given that we know being present at the birth of their child(ren) is a huge life event for them and that becoming a parent is a big life shift for all, it is important that we think carefully about their wants and needs.

I have been running NCT antenatal courses for sixteen years and have always had a real interest in working with the dads. This led me to run dads only courses through my local Children’s Centre – Mantenatal – for several years (until sadly we lost the funding) and I still do dads/partners only sessions within my NCT courses.

It is perhaps not surprising that much of the focus from others, including health professionals, during pregnancy is on the mums. We have a real opportunity within our courses to give some emphasis to the dads.

As practitioners, we often talk about aiming to increase mums’ self-efficacy around birth and becoming a mum. We are very aware of the underlying views they might have about these things from the birth stories they have heard anecdotally and in the media. It is interesting to think about this for dads too – often, dads are portrayed during labour as out of their depth, feeing like a spare part or panicking. New dads are often perceived to be disorganised and struggling. On top of this, we should be aware of relatively recent changes to fathers’ roles during the transition to parenthood. For example, the current series of Call the Midwife (in 1962) still mostly shows dads outside the birth room. It is perhaps not surprising that fathers often feel unsure of their role and lack confidence. By allowing time to explore their fears and expectations, we can make a real difference to their self-efficacy both as a birth partner and a new dad.

NCT practitioners are equipped with the skills and knowledge to include and engage dads, and we have our own strategies and tips that we have developed over time. Here are a few thoughts based on my experiences:

  • Set the scene from the beginning that the dads are very much part of the course – you can do this in the first session by exploring their point of view. What are their concerns? How confident are they feeling? Ensuring that you explore these things as individuals rather than couples makes a big difference. Later in the course, if you are looking at a topic, ensure you cover both perspectives – how might a father feel during a caesarean birth for example?
  • Think about the language that you use. Every time you say ‘your cervix’ or ‘when you experience contractions’, you are excluding half the group. This isn’t always easy, but trying hard to describe things in an inclusive way really helps to engage with the dads.
  • Acknowledge that although their role during labour is to support their partner, it is often a powerful experience for them too. Spend time exploring the emotions that it might bring for them, and the affect that could have on themselves and their partners. This might include encouraging them to think about who they could talk to about their experiences after the birth, when much of the focus will be on the baby and their partner.
  • Ensure that you include dads’ voices and images – if using birth stories, have some from dads, and include photos of dads with their babies.
  • When doing things like bathing or nappy changing, try and make sure mums and dads have a chance to have a go and acknowledge that there are often not right or wrong ways to do things: mums and dads might do things differently.
  • Giving the dads space to explore their point of view – one of the main ways I do this is with the dads/partners only session. I invite two dads from a previous group to come along with their babies, and for half an hour the expectant dads can ask them anything they want to. We then spend the rest of the session exploring labour and particularly early parenting from their point of view. This gives a fantastic opportunity for them to open up about things – in a recent session, a dad shared how his previous relationship had broken down when he felt unable to share how hard he was finding thigs as a new dad. Giving fathers time to think about how they will support their partners, but also be aware of their own wellbeing, is so important. I appreciate not everyone will want/feel able to offer a separate session but some of this could be incorporated into a couple’s session by using group work.

Is Dad OK? New fathers and mental health difficulties

Ranjana Das and Paul Hodkinson, University of Surrey

The announcement that the NHS will begin screening some new fathers for mental health issues reflects increasing evidence that dads can suffer from anxiety, depression and other wellbeing issues after having a baby. It also responds to vigorous campaigning from activists and charities on the subject and addresses the difficulties men can have with seeking support for mental health challenges. 

Yet, the post-natal struggles new fathers can encounter continue often to be overlooked in conversations about the wellbeing of new parents and how to support them. Building on our existing interests in mothers and wellbeingand caregiving fathers, we interviewed 15 fathers who had experienced mental health difficulties after having a baby.  

Here we outline findings and recommendations we hope will be useful for antenatal and post-natal practitioners, who are in a unique position to help alleviate some of the issues we highlight. 

Contributing circumstances

The fathers typically reported symptoms resembling anxiety and/or depression, with a minority outlining more specific conditions. A range of contributing circumstances were described, some of which comparable to issues faced by mothers and others more distinct. The most prevalent included:

  • the negotiation and aftermath of difficult pregnancies and/or traumatic births
  • everyday post-natal challenges relating to sleep, constant crying, juggling of responsibilities and isolation
  • struggles to come to terms with dramatic changes of identity and responsibilities 
  • baby’s mother suffering depression, anxiety or physical difficulties recovering from birth
  • the weight of masculine expectations – to support, carry on, be strong 

The last of these, we found, often connected to all the others, with fathers often experiencing spirals of guilt at what felt like a failure to live up to their ideals of what a new father should be. 

Difficulties recognising and reaching out

Difficulties understanding and talking about their struggles often made fathers’ struggles worse. Typically, it had taken several months, and sometimes a crisis or breakdown, before professional help was sought. Reaching out to partners and/or friends and family often remained a struggle for longer. Key factors here included the following: 

  • Lack of prior knowledge about new fathers and mental health made it difficult to recognise the seriousness of the problem. Many were not aware that fathers could suffer from post-natal mental health difficulties. 
  • Fathers often interpreted their struggles as a personal failure as a man and father, and refused to regard their problems as legitimate as compared to their partners’ situation.
  • A sense of failure to live up to masculine expectations – to support, rather than being supported – often prevented men from talking about their difficulties with friends, family and, sometimes, partners.
  • Fathers often had minimal contact with communities of other new parents, limiting opportunities to speak to others in similar circumstances.

Relief via social media?

At one point or another, many fathers had turned to social media, though uses were diverse and such platforms should not be viewed as a magic solution. Going online did often help with finding information and connecting to other sufferers, as well as offering potentially useful channels through which to talk about their own struggles. 

In particular we found that:

  • Engaging with others’ struggles often helps. Encountering the accounts of other sufferers on blogs, online communities or individual social media accounts helped provide understanding and a sense that their own difficulties were legitimate, easing self-blame.
  • It can be easier to talk about problems online. Several fathers had found it easier opening up to strangers or distant acquaintances online, free from the burdens of existing relationships and the awkwardness of face-to-face encounters.
  • Social media can enable people to send out ‘coded’ cries for help. Those most reluctant to talk directly about their struggles sometimes felt able to subtly hint at them in the hope someone might notice and respond.
    • Examples included ‘liking’ or sharing general articles about depression, responding supportively to others, or even going silent for a time.
    • While this sometimes triggered support and enduring relationships, such coded gestures sometimes remained unnoticed or unanswered.   

Moving Forward: Helping fathers to understand, cope and communicate

We would particularly highlight the following lessons from our research as areas for consideration for antenatal and post-natal practitioners.

  • We need to better inform and prepare fathers for the difficulties they could face
    • Greater awareness of the possibility of male post-natal mental health struggles could help alleviate spirals of self-blame and damaging delays with seeking support. 
    • The problems dads can encounter could be covered, alongside maternal mental health questions, as part of antenatal classes, and dealt with more prominently in online and other resources oriented to parents-to-be.
  • Fathers need more networks of support during the post-natal period to help their general wellbeing and enable them to recognise symptoms and seek help if necessary.
    • We need to make it easier for fathers to access supportive groups of new dads, or mixed-gender parent groups that welcome then.
    • As well as setting up or facilitating new fathers groups, it would be invaluable to provide more information about existing groups.
    • Since fathers sometimes find it easier to engage with mental health issues online, we should help them find and become involved in online as well as face-to-face groups. 
  • We need to recognise and revise some of the expectations placed on new fathers and establish that it is OK for them to need support.
    • Our research highlights the potential negative impact of intense pressures on fathers to provide ‘rock-like’ support and be strong at all costs.
    • The nature of such pressures and how to deal with them could be explicitly discussed as part of antenatal and post-natal courses and/or online materials
    • It would be useful also to review existing content and its delivery to ensure such pressures are not inadvertently being reinforced.

Further Information and Resources

NCT website article on postnatal depression and dads: https://www.nct.org.uk/life-parent/dads-and-partners/postnatal-depression-dads-10-things-you-should-know

NCT website dads and partners section: https://www.nct.org.uk/life-parent/dads-and-partners

Andrew Mayers’ fathers and mental health site, including links to various resources: http://www.andrewmayers.info/fathers-mental-health.html

Bluebell ‘dads in mind’ site: http://www.bluebellcare.org/index.php?page=dads-in-mind

Make Birth Better site (including resources for fathers/partners): https://www.makebirthbetter.org/

PANDAS Dads site (a Facebook group for fathers coping with postnatal mental health issues) https://www.facebook.com/pandasdads/

Fatherhood and Mental Health Website by Mark Williams   http://www.reachingoutpmh.co.uk/

Dads Matter UK – website for a charity fathers and mothers with mental health difficulties https://www.dadsmatteruk.org/