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/

Why charities sometimes need to do less

Saying goodbye to long-standing and valued colleagues is always hard and there was sadness last month when NCT said goodbye to the small MIDIRS (Midwives Information and Resource Service) team who transferred over to the Royal College of Midwives (RCM).

Along with the card, cake and speeches, there was the inevitable sense of loss – but I was also optimistic about the new arrangement.

MIDIRS was born 34 years ago when a group of midwives recognised the need to provide information, research and guidance in order to support others in their profession.

It began life as an independent charity and within a short time grew to be a stalwart of the midwifery community. Having worked well together for a number of years, MIDIRS approached NCT with a proposition and in 2011 the two charities officially merged.

Today, MIDIRS has a world-class reputation for excellence, high quality, accessible information and is well loved. It also has strong leadership, generates income and lives within its means. So if it ain’t broke, why fix it?

During the first few months of working at NCT, when learning more about our services for parents, I was struck by the significant difference of the MIDIRS portfolio. Its core audience is healthcare professions, who in turn serve parents, whereas the vast majority of NCT’s work is directly with new mums and dads.

While supporting healthcare professionals is well within our charitable mission, MIDIRS within NCT had to work really hard to reach midwives and midwifery students. MIDIRS was an important adjunct to the work of NCT but rarely featured in our discussions around future strategy or areas where we recognized the need to develop.

In short, it didn’t take long to see that MIDIRS appeared to be sitting in the wrong chair. It was taking NCT cost and effort to reach MIDIRS’ core audience of midwives, maternity assistants and midwifery students which the RCM already has.

It’s easy for charities to focus on growth and continually do more in order to deliver on their charitable objectives, but this situation showed that there can be benefits to questioning this approach. In certain situations, a charity stopping parts of its work can be the best way forward.

Negotiations between RCM and NCT’s Board have taken time and effort, but the result is an arrangement that works better for all three organisations. MIDIRS has a new home with the RCM and is much closer it is audience. RCM it has the chance to ensure all its members benefit from MIDIRS.

NCT is proud of how we’ve helped MIDIRS on its way, secure in the knowledge that better informed midwives serve parents better. We also have the added benefit of more headspace to focus on our core business: improving support for parents through the first thousand days.

Sometimes in order to do more to support their beneficiaries, charities need to think about doing less.