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Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety Shwu-Ru Liou, PhD, RN (Associate Professor)a, Panchalli Wang, MD (Medical Doctor)b, Ching-Yu Cheng, PhD, RN (Associate Professor)a,n a b

School of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Taiwan Department of Obstetrics and Gynaecology, Chia-Yi Christian Hospital, Taiwan

art ic l e i nf o

a b s t r a c t

Article history: Received 25 April 2013 Received in revised form 17 September 2013 Accepted 18 November 2013

Objectives: to understand the trends in, and relationships between, maternal stress, depressive symptoms and anxiety in pregnancy and post partum. Design: a prospective longitudinal survey study was undertaken to explore maternal psychological distress throughout the perinatal period. The participants were recruited after 24 completed weeks of gestation, and were followed-up monthly until one month post partum (four surveys in total). Setting: participants were recruited from a single hospital in southern Taiwan, and asked to complete questionnaires in the hospital waiting area. Participants: inclusion criteria were: age Z18 years, able to read and write Chinese, Z 24 weeks of gestation, singleton pregnancy and no pregnancy complications (including a diagnosis of antenatal depression or anxiety disorder). In total, 197 women completed all four surveys (response rate 74.62%). Measurements and findings: stress was measured with the 10-item Perceived Stress Scale, depressive symptoms were measured with the Center for Epidemiologic Studies' Depression scale, and anxiety was measured with the Zung Self-reported Anxiety Scale. Participants were followed-up at four time points: T1 (25–29 gestational weeks), T2 (30–34 gestational weeks), T3 ( 434 gestational weeks) and T4 (4–6 weeks post partum). Appointments for data collection were made in accordance with the participants' antenatal and postnatal check-ups. The three types of maternal distress had different courses of change throughout the perinatal period, as levels of depressive symptoms remained unchanged, anxiety levels increased as gestation advanced but declined after birth, and stress decreased gradually during pregnancy but returned to the T1 level after birth. There was a low to high degree of correlation in maternal stress, depressive symptoms and anxiety in pregnancy and post partum. Key conclusions: around one-quarter of the study participants had depressive symptoms during pregnancy and post partum. Stress and anxiety showed opposing courses during the perinatal period. Regardless of the trend, maternal mental distress returned to the T1 level after birth. Implications for practice: effective survey questionnaires are suggested for use as primary screening for possible psychological distress among pregnant and post partum women. It is suggested that health care professionals involved in obstetrics and midwifery should pay attention to the psychological needs of pre- and postnatal women, provide women with sufficient information about their mental well-being, and make appropriate and timely referrals to psychiatric or psychological care. & 2013 Elsevier Ltd. All rights reserved.

Keywords: Maternal stress Maternal depressive symptoms Maternal anxiety Perinatal

Introduction Perinatal maternal mental health has gained increasing attention because certain forms of psychological distress experienced by pregnant or post partum women not only have an immediate impact on birth outcomes, but also have long-term effects on the

n Correspondence to: School of Nursing, Chang Gung University of Science and Technology, No. 2, Chiapu Rd. West Sec., Putz City, Chiayi 613, Taiwan. E-mail address: [email protected] (C.-Y. Cheng).

health of mothers, infants/children and the whole family (Dunkel Schetter and Tanner, 2012). The most common types of perinatal maternal mental distress investigated and discussed in the published literature are depression/anxiety and stress in daily life (Dipietro et al., 2008; Dunkel Schetter and Tanner, 2012). Maternal depression or anxiety alone during the perinatal period has been found to be related to adverse outcomes, such as excessive activity or growth delay (fetuses); preterm childbirth; low birth weight, disorganised sleep or less responsive to stimuli (newborns); underweight, growth delay, negative affection or poor mother–infant relationship (infants); attention deficiency,

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.11.007

Please cite this article as: Liou, S.-R., et al., Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.11.007i

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emotional instability or behavioural problems (children/adolescents); decreased likelihood for new mothers to breast feed; and parental stress after childbirth (Britton, 2007; Marina et al., 2008; Van den Bergh et al., 2008; Tronick and Reck, 2009; Field, 2010; Grote et al., 2010; Misri et al., 2010; Thompson and Fox, 2010; Insaf et al., 2011). Previous research has suggested that the incidence of prematurity is higher in the offspring of women with comorbid depression and anxiety compared with the offspring of women with depression or anxiety alone (Field et al., 2010). In addition, the maternal perception of stress has been found to be related to pregnancy complications and paediatric health, such as decreased likelihood of breast feeding, post partum depression, preterm childbirth, caesarean section, separation anxiety disorder, attention deficit–hyperactivity disorder and conduct disorders in children (Abeysena et al., 2010; Martini et al., 2010; Chuang et al., 2011; Insaf et al., 2011; Roy-Matton et al., 2011; Tegethoff et al., 2011). The adverse effects of psychological distress during pregnancy and post partum have been validated, but the changing courses and relationships of perinatal maternal mental distress are rarely discussed. By depicting the trends in, and relationships between, types of maternal mental distress throughout the perinatal period, suitable preventive or treatment interventions can be adopted at the right time to ameliorate or alleviate the seriousness of distress for women during pregnancy and post partum. Longitudinal studies have been conducted to understand the changing courses of perceived stress, depression and anxiety from pregnancy to post partum, but they have either focused on depression alone (Evans et al., 2007; Lee et al., 2007; Mora et al., 2008; Lau et al., 2010; Bowen et al., 2012; Melo et al., 2012) or solely on the period of pregnancy (Parcells, 2010). Very few studies have explored the trends in, and relationships between, stress, depressive symptoms and anxiety throughout the perinatal period (Dipietro et al., 2008). The present study was undertaken to investigate maternal stress, depression and anxiety from pregnancy to post partum, guided by the following research questions: (1) What are the trends in maternal perceived stress, depressive symptoms and anxiety from pregnancy to post partum? (2) What are the relationships between maternal perceived stress, depressive symptoms and anxiety from pregnancy to post partum?

Methods Design This prospective, longitudinal study explored maternal psychological distress from pregnancy to post partum. The participants were recruited after they reached 24 completed weeks of gestation, and were followed-up monthly until one month post partum (four surveys in total). Setting Participants were recruited from a single hospital in southern Taiwan. Participants were asked to complete the questionnaires in the hospital waiting area. Sampling The inclusion criteria were: age Z18 years, able to read and write Chinese, Z24 weeks of gestation, singleton pregnancy and no pregnancy complications (including a diagnosis of antenatal depression or anxiety disorder). Initially, a pilot study with a sample size of 130 was conducted. The pilot study found correlation coefficients between stress, depressive symptoms and anxiety

of r ¼  0.45 to 0.66; as such, the GnPower statistical power analysis program indicated that 44 participants were needed for power of 90%. It was anticipated that this study might have a high attrition rate due to its longitudinal design (Gustavson et al., 2012); therefore, as many pregnant women as possible were recruited between February 2010 and October 2011. Initially, 264 pregnant women were approached, and 56 declined to participate in the study. As such, 208 participants completed the first survey (T1: 25–29 gestational weeks). Eleven pregnant women dropped out after completing the second survey (T2: 30–34 gestational weeks), but 197 women completed the study, reflecting a response rate of 74.62%. One pregnant woman did not complete the T2 survey and three did not complete the T3 survey (434 gestational weeks) due to preterm birth; therefore, 196 and 194 questionnaires were analysed for T2 and T3, respectively. There were no differences in demographic variables, including age, marital status, parity, educational level, employment and planned pregnancy, between women who dropped out and women who remained in the study. A trained research assistant approached potential participants awaiting antenatal check-ups in the waiting area. Women decided if they wished to participate following an explanation of the purpose of the study and their rights. The participants were encouraged but not obligated to complete the study. As shown in Table 1, the mean age of the participants was 29.71 years, and the mean gestational age at T1 was 27.34 weeks. The majority of the participants were primiparas. Almost all of the participants were married or cohabiting, and most of them had planned their pregnancy. Approximately two-thirds of the

Table 1 Demographic profile of the study participants. Mean

SD

Range

29.71 27.34 31.83 35.64 38.20 3028.12

4.42 1.08 0.80 0.73 1.37 341.43

19–42 25–29 30–34 34–38 32–41 1820–3940

n

%

Parity Primipara Multipara

111 86

56.3 43.7

Marriage Married/cohabiting Not married

195 2

99.0 1.0

Planned pregnancy Yes No

101 96

51.3 48.7

Education Less than college College or higher

63 134

32.0 68.0

Employment Employed Unemployed

118 79

59.9 40.1

Maternal leave Paid leave Non-paid leave No leave

159 35 3

80.5 17.8 1.7

Birth method Vaginal childbirth Caesarean section Low-birthweight infant ( o2500 g)

143 54 11

72.6 27.4 5.6

Age (years) Gestational age at T1 (weeks) Gestational age at T2 (weeks) Gestational age at T3 (weeks) Gestational age at birth (weeks) Infant birth weight

T1, 25–29 gestational weeks; T2, 30–34 gestational weeks; T3, 434 gestational weeks; T4, 4–6 weeks post partum; SD, standard deviation.

Please cite this article as: Liou, S.-R., et al., Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.11.007i

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participants had a college education or higher. Most of the participants were employed; of these, most had paid maternity leave, some had unpaid leave and a few did not have any maternity leave. Most of the participants had a vaginal childbirth. The mean birth weight of their newborns was 3028.12 g, and 11 infants had low birth weight (o2500 g). The mean gestational age at birth was 38.20 weeks. Instruments Three instruments were used to assess the participants' perceived levels of stress, depressive symptoms and anxiety. Stress The 10-item Perceived Stress Scale (PSS-10) was used to measure the degree by which situations were appraised as stressful in one's life (Cohen and Williamson, 1988). This is a 10-item, five-point scale, ranging from 0 to 4. A higher score on the PSS-10 indicates a higher level of perceived stress. The PSS has been widely used among pregnant and postnatal women (Dipietro et al., 2008; Parcells, 2010; Malta et al., 2012). The scale has been translated into Chinese and used among Chinese mothers (Cheng and Pickler, 2009; Mao et al., 2011), and the reliability of the Chinese version is satisfactory (Cronbach's alpha ¼ 0.87). Depressive symptoms The Center for Epidemiologic Studies' Depression (CES-D) scale is a 20-item, four-point (0–3) response self-reported scale, with Cronbach's alpha ranging from 0.84 to 0.90. Test–retest correlations at two, four, six and eight weeks have been reported to be satisfactory (ranging from 0.51 to 0.67) (Radloff, 1977). The higher the score, the greater the likelihood that an individual will experience depressive symptoms. A cut-off score of 16 was suggested for use (Radloff, 1977). The CES-D scale has been used with pregnant women and post partum mothers with high Cronbach's alpha scores (Cheng and Pickler, 2009; Mao et al., 2011). The Cronbach's alpha for T1 in the present study was 0.89. Anxiety The Zung Self-reported Anxiety Scale (SAS), a 20-item, fourpoint (1–4) scale, was developed to evaluate the presence of anxiety (Zung, 1971). A higher score indicates a higher level of anxiety. The SAS has been validated in Chinese women with a history of spontaneous abortion or induced abortion during a subsequent pregnancy, with satisfactory internal consistency (Cronbach's alpha ¼0.81) (Huang et al., 2012). The reliability of the SAS was tested using T1 data. Results showed that Cronbach's alpha was 0.65, and two items had negative and low item-total correlation. By deleting these two items (r ¼  0.02 for item ‘I can breathe in and out easily’; r ¼ 0.14 for item ‘I fall asleep easily and get a good night's rest’), Cronbach's alpha increased to 0.71 and factor analysis showed that the remaining 18 items could explain 53.39% of the variance in anxiety. The 18-item SAS was used in this study. Procedure Before the study commenced, the study protocol was approved by the Institutional Review Board of the participating hospital. Participants were recruited via professional referral and personal contact in the hospital. All participants were asked to complete a set of paper questionnaires. Participants were followed up monthly until one month post partum (T1: 25–29 gestational weeks, T2: 30–34 gestational weeks, T3: 4 34 gestational weeks, T4: 4–6 weeks post partum). Appointments for data collection

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were made in accordance with the participants' antenatal and postnatal check-ups. All data were entered in the primary investigator's personal computer, which was password protected, and only the primary investigator knew the password. The paper questionnaires were stored in a locked cabinet in the primary investigator's office. Only the primary investigator had the key to the room and the cabinet. All paper questionnaires were anonymous and contained no information that could identify the participants. Data analysis Collected data were managed and analysed using SPSS Version 18.0 (IBM Corp., New York, USA). Descriptive statistics were used to understand the participants' demographic information and levels of measured variables. Pearson's correlation was used to test relationships between measured variables, and the Generalised Estimation Equation was used to test changes in measured variables by time point.

Findings Trends in stress, depressive symptoms and anxiety from pregnancy to post partum Table 2 shows that, after controlling for confounding demographic variables, the participants' stress level decreased gradually from T1 to T3, but returned to the T1 level after giving birth. On the other hand, the level of anxiety increased from T1 to T2, remained the same at T3, and then declined dramatically to a level lower than T1 after birth. However, the level of depressive symptoms remained unchanged over time. Trends in each type of maternal distress at various time points are illustrated in Fig. 1. The occurrence of depressive symptoms at T1, T2, T3 and T4 was 25.9%, 25.5%, 24.2% and 27.4%, respectively. Using T1 as the referent, there was no difference in the occurrence of depressive symptoms at T2 (Wald χ2 ¼0.02, p ¼0.88), T3 (Wald χ2 ¼ 0.29, p¼ 0.59) or T4 (Wald χ2 ¼0.16, p ¼0.69). Of the participants who experienced depressive symptoms post partum (n ¼54), 68.5% also experienced depressive symptoms during pregnancy (49.0% at T1, 58.0% at T2 and 48.9% at T3). Further analyses found that of those who experienced depressive symptoms at T1 (n ¼ 51), 58.8% Table 2 Comparison of stress, depressive symptoms and anxiety at different time periods. Mean 7SD

B

Wald χ2

p

95% CI

17.177 5.21 16.46 7 5.18 16.30 7 5.16 17.047 5.72

 0.72  0.88  0.14

7.92 9.90 0.13

0.01 0.002 0.72

 1.21 to  0.22  1.42 to  0.33  0.89 to 0.61

Depressive symptoms T1 (referent) 11.167 8.32 T2 11.53 7 8.04 T3 11.167 7.89 T4 10.747 11.01

0.34  0.04  0.45

0.63 0.01 0.32

0.43 0.93 0.58

 0.50 to 1.17  0.89 to 0.82  2.01 to 1.12

Anxiety T1 (referent) T2 T3 T4

2.40 2.41  2.18

20.25 16.26 11.37

o 0.001 o 0.001 0.001

1.35 to 3.44 1.24 to 3.57  3.45 to  0.92

Stress T1 (referent) T2 T3 T4

41.28 7 7.53 43.69 7 6.75 43.62 7 7.51 39.02 7 7.10

T1, 25–29 gestational weeks; T2, 30–34 gestational weeks; T3, 434 gestational weeks; T4, 4–6 weeks post partum; SD, standard deviation; CI, confidence interval. Confounding demographic variables controlled for stress and depressive symptoms included parity, employment, education and planned pregnancy, whereas none of the demographic variables were controlled for anxiety.

Please cite this article as: Liou, S.-R., et al., Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.11.007i

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Fig. 1. Trends in stress, depressive symptoms and anxiety from pregnancy to post partum. T1, 25–29 gestational weeks; T2, 30–34 gestational weeks; T3, 434 gestational weeks; T4, 4–6 weeks post partum.

(n ¼30) also experienced depressive symptoms at T2; of those who experienced depressive symptoms at T1 and T2, 83.3% (n ¼25) also experienced depressive symptoms at T3; and of those who experienced depressive symptoms at T1, T2 and T3, 64% (n ¼ 16) also experienced depressive symptoms at T4. Therefore, 8.1% (n ¼16) of the study participants experienced depressive symptoms from T1 to T4. The present study can only generate point prevalence of depressive symptoms because the other two assessment tools did not have a cut-off point. Correlations between measured variables at different time points Table 3 shows that stress, depressive symptoms and anxiety were significantly related to each other across all time points, and the intercorrelations at different time points also reached statistical significance. All correlations were significant at p o0.001, except the relationships between anxiety at T1 and stress and depressive symptoms at T4 (po 0.05).

Discussion This study found low to high degrees of correlation between maternal stress, depressive symptoms and anxiety from pregnancy to post partum. All measured maternal distress variables had different courses of change throughout the perinatal period. Trends in stress, depressive symptoms and anxiety from pregnancy to post partum The trends in maternal distress variables were diverse; perinatal maternal depressive symptoms remained unchanged throughout, whereas anxiety and stress had opposite courses of change from mid-pregnancy to early post partum. The finding that stress first decreased and then increased from pregnancy to post partum was consistent with previous research studies conducted by Parcells (2010), who found a lower PSS score during pregnancy, and Dipietro et al. (2008), who found a higher mean PSS score from pregnancy to six weeks post partum. Other studies generated incongruent results on maternal stress during pregnancy: Da Costa et al. (1999) found that general stress scores were quite stable throughout pregnancy, whereas Thompson et al. (1997) found higher frequency of general stress during the later stages of pregnancy. Due to these conflicting results, more research is warranted to better understand the changes in perceived stress during pregnancy. In addition, an increase in the level of maternal stress from pregnancy to post partum may indicate that physiosocial and maternal role changes after childbirth bring new issues to mothers. The adaptation of mothers to post partum changes may need to be assessed, and difficulties in adaptation need to be managed.

The present finding that the level of perinatal depressive symptoms remained unchanged over time was consistent with some previous studies (Dipietro et al., 2008; Grant et al., 2008), but different from others. For example, Bowen et al. (2012) found a consistent decrease in the Edinburgh Post-Natal Depression Scale (EPDS) mean score of Canadian mothers, whereas Lau et al. (2010) found a decrease–increase trend in the EPDS mean score from pregnancy to post partum among Chinese mothers. Although Evans et al.'s (2007) study in the UK found a small increase in depressive symptoms during pregnancy and a small decrease post partum, they proposed that the significant difference was due to a large sample size. Furthermore, the results of the present study – that the mean score for depressive symptoms remained unchanged and the point prevalence of maternal depressive symptoms was stable over time – were consistent with previous studies in the UK and Australia (Evans et al., 2007; Grant et al., 2008). The consistency and inconsistency in patterns of depressive symptoms from pregnancy to post partum suggests the need to conduct further prospective longitudinal studies on pregnant women of diverse ethnicities. Regardless of the patterns of perinatal depressive symptoms, the present study found that approximately one-quarter of pregnant and post partum women were at risk for developing depression, and approximately half of women who experienced depressive symptoms at some point during pregnancy also experienced depressive symptoms post partum. A high percentage of pregnant women who experienced depressive symptoms continuously experienced the symptoms in the next stage of pregnancy and post partum. This result highlights the need for maternal depressive symptoms to be assessed and managed early during pregnancy and followed-up until post partum. In addition, non-pharmacological interventions such as informational and educational programmes, selfmanagement training programmes and supportive programmes that improve or prevent perinatal depression are suggested for pregnant women at risk of depression (Milgrom et al., 2011; Mao et al., 2012; Songøygard et al., 2012; Kieffer et al., 2013). Other interventions such as cognitive behaviour programmes or exercise programmes that have shown inconsistent effects on depressive symptoms warrant more prospective studies to evidence their positive effects on perinatal depression (Austin et al., 2008; Robledo-Colonia et al., 2012; O’Mahen et al., 2013). Nevertheless, cultural appropriateness and modifications of the interventional programmes may be required before implementation. The increase and subsequent decrease in anxiety from pregnancy to post partum found in the present study echoed the result from Dipietro et al.'s (2008) study; however, it differed from Grant et al.'s (2008) study in that the decrease in mean anxiety scores from pregnancy to post partum was not significant. During pregnancy, some studies found an increasing trend in perceived anxiety (Da Costa et al., 1998, 1999), whereas others found that the

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Table 3 Correlations between measured variables at different time points.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

T1 T1 T1 T2 T2 T2 T3 T3 T3 T4 T4 T4

stress depressive anxiety stress depressive anxiety stress depressive anxiety stress depressive anxiety

symptoms

symptoms

symptoms

symptoms

1

2

3

4

5

6

7

8

9

10

11

1 0.71nn 0.33nn 0.76nn 0.59nn 0.41nn 0.72nn 0.59nn 0.46nn 0.52nn 0.33nn 0.35nn

1 0.51nn 0.67nn 0.74nn 0.50nn 0.58nn 0.72nn 0.52nn 0.44nn 0.35nn 0.31nn

1 0.33nn 0.42nn 0.46nn 0.31nn 0.43nn 0.40nn 0.20n 0.19n 0.39nn

1 0.71nn 0.52nn 0.76nn 0.65nn 0.56nn 0.56nn 0.35nn 0.38nn

1 0.59nn 0.62nn 0.80nn 0.62nn 0.49nn 0.41nn 0.43nn

1 0.54nn 0.57nn 0.74nn 0.47nn 0.27nn 0.38nn

1 0.71nn 0.67nn 0.52nn 0.32nn 0.37nn

1 0.71nn 0.43nn 0.39nn 0.50nn

1 0.41nn 0.28nn 0.63nn

1 0.75nn 0.68nn

1 0.68nn

T1, 25–29 gestational weeks; T2, 30–34 gestational weeks; T3, 434 gestational weeks; T4, 4–6 weeks post partum. n

po 0.05. p o0.001.

nn

level of anxiety was fairly stable (Parcells, 2010). It is not understood whether these disparities were due to different measurement tools or the ethnicities of the study populations. Regardless, certain levels of anxiety were perceived by pregnant and post partum women, and interventions such as imagery or relaxation education programmes that show positive effects on anxiety and pregnancy outcomes may be implemented during pregnancy (Bastani et al., 2005, 2006; Marc et al., 2011). Correlations between measured variables at different time points Although correlation was found between stress, depressive symptoms and anxiety at each time point, the power of the relationship was quite diverse. High correlation was found for antenatal stress at different time points throughout pregnancy and post partum. The same was found for depressive symptoms, and the effect size decreased from high during pregnancy to mediumhigh post partum. Such changes could be attributed to the fact that the contributing factors for feeling stressed or depressed during pregnancy and post partum may be different. In their metaanalysis, Littleton et al. (2007) found moderate correlation between anxiety and depressive symptoms (r ¼0.66), as well as between anxiety and stress (r ¼0.44). Dipietro et al. (2008) found a wider range of correlation from a low of r ¼0.19 to a high of r ¼0.73 among different measurements of anxiety, stress and depressive symptoms; however, this analysis was based on a single time point. Maternal stress, depressive symptoms and anxiety were correlated throughout pregnancy and post partum, regardless of the strength of the effect sizes. In addition, although stress, depressive symptoms and anxiety were intercorrelated, their relationship was not equally distributed. This study found that stress and depressive symptoms had a strong, stable relationship throughout the perinatal period, but anxiety seemed to have a rather weak relationship with both stress and depressive symptoms. Lancaster et al. (2010) found that maternal anxiety and life stress were associated with antenatal depressive symptoms in bivariate analyses, but only life stress continued to show a significant correlation in multivariate analyses. There was also a time effect for the relationship between anxiety and stress, as well as between anxiety and depressive symptoms. As the fetus approached term, the relationship between anxiety and stress increased and remained intact until after birth, as did the relationship between anxiety and depressive symptoms. This revealed that the comorbidity of anxiety and depressive symptoms was more obvious closer to term, in line with a previous study by Lee et al. (2007) which found that the comorbidity rate of anxiety and depression increased from the

second to the third trimester. The high inter-relatedness between measured variables was also reported by Dipietro et al. (2008), who postulated that either there are comorbidities between these three psychological variables or self-administered questionnaires cannot distinguish between these three aspects of mental distress, which means that certain survey questions measure both or all dimensions of these mental problems. Similarly, Hirschfeld and Robert (2001) pointed out that anxiety and depression are not easily distinguishable because of their overlapping symptoms. The increased level of anxiety and high level of depression symptoms in late pregnancy may make the comorbidity of anxiety and depressive symptoms more obvious in late pregnancy. For this reason, women who experience depressive symptoms or anxiety may also need to be assessed for other cormorbid mental distress. Very few studies have been undertaken to test interventions to manage stress, anxiety and depression together. Interventions such as mindfulness meditation, self-awareness and help interventions that showed positive effects on non-pregnant people's stress, depression or anxiety levels could be applied for pregnant women (van Straten et al., 2008; Kang et al., 2009). Study limitations In spite of the strengths of its longitudinal design and low attrition rate, this study had some limitations. Only pregnant women in a single hospital in southern Taiwan were surveyed, so the generalisability of the findings is limited. In addition, due to the survey instruments used and the time points selected, the ability to compare data between studies is also limited. Furthermore, clinical diagnostic interviews were not conducted to confirm psychiatric disorders, and the use of self-report questionnaires may have underestimated (Parcells, 2010) or overestimated (Melo et al., 2012) the prevalence of maternal mental distress during pregnancy and post partum. Therefore, it is recommended that future longitudinal investigations should recruit participants from other hospitals located in northern and mid Taiwan to increase generalisability. In addition, more evidence-based studies with similar research designs need to be conducted across countries so that the results can be compared to reach consensus in this field.

Conclusion Using a longitudinal design, this prospective study illustrated the trends in, and relationships between, stress, depressive symptoms and anxiety from pregnancy to post partum. Approximately one-quarter of the study participants had depressive symptoms

Please cite this article as: Liou, S.-R., et al., Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.11.007i

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throughout the perinatal period. The changing courses of maternal stress and anxiety were inversely correlated; pregnant women felt less stressed but more anxious when closer to term, whereas new mothers perceived higher levels of stress but were less anxious after birth. Regardless of trends during pregnancy, it seemed that maternal mental distress returned to the T1 level after birth. This study confirmed that maternal mental distress has a changing pattern (Lee et al., 2007), and it is important for health professionals to detect the mental states of pregnant women as early as possible in order to provide proper management for their wellbeing in pregnancy and post partum. For early detection, effective survey questionnaires are suggested for use as primary screening for possible psychological distress among pregnant and post partum women. For proper management, it is recommended that health care professionals should pay extra attention to the psychological needs of pre- and postnatal women, provide them with sufficient information about their mental well-being, and make appropriate and timely referrals to psychiatric or psychological care that may not only prevent mental distress but also increase women's quality of life (Da Costa et al., 2010; Bos et al., 2013). Interventions such as informational and educational programmes, self-awareness and management training programmes, supportive programmes, imagery, mindfulness meditation and relaxation education programmes that have been shown to have positive effects on reducing stress, depression and anxiety may be implemented in women with high scores on stress, depressive symptoms and anxiety scales (Bastani et al., 2005, 2006; van Straten et al., 2008; Kang et al., 2009; Marc et al., 2011; Milgrom et al., 2011; Mao et al., 2012; Songøygard et al., 2012; Kieffer et al., 2013).

Acknowledgements The authors would like to thank Chang Gung Medical Research Programme, Taiwan (CMRPF680042) for funding the study.

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Please cite this article as: Liou, S.-R., et al., Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.11.007i

Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety.

to understand the trends in, and relationships between, maternal stress, depressive symptoms and anxiety in pregnancy and post partum...
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