Measures of anxiety, depression and stress in the antenatal and perinatal period following a stillbirth or neonatal death: a multicentre cohort study

Abstract

Background: The grief associated with the death of a baby is enduring, however most women embark on another pregnancy, many in less than a year following their loss. Symptoms of anxiety and depression are reported to be increased in pregnancies after perinatal death, although effect on maternal stress is less clear. Variation between individual studies may result from differences in gestation at sampling, the questionnaire used and the type of antecedent perinatal death. We aimed to describe quantitative measures of anxiety, depression, stress and quality of life at different timepoints in pregnancies after perinatal death and in the early postnatal period.

Methods: Women recruited from three sites in the North-West of England. Women were asked to participate if a previous pregnancy had ended in a perinatal death. Participants completed validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score) and health status (EQ-5D-5L™ and EQ5D-Visual Analogue Scale) at three time points, approximately 15 weeks' and 32 weeks' gestation and 6 weeks postnatally. A sample of hair was taken at approximately 36 weeks' gestation for measurement of hair cortisol in a subgroup of women. The hair sample was divided into samples from each trimester and cortisol measured by ELISA.

Results: In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks' gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p<0.001). Hair cortisol levels fell in a similar profile to anxiety and depression symptoms (p<0.05). In contrast, the median EQ-5D index, measuring health status was 0.768 at 15 weeks' gestation (Interquartile range (IQR) 0.684-0.879), 0.696 at 32 weeks' (IQR 0.637-0.768) and 0.89 (0.760-1.00) at 6 weeks postnatal. There was a negative relationship between EPDS and perceived health status.

Conclusions: This study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels in women in pregnancies after a stillbirth or neonatal death which decrease as pregnancy progresses. Further studies are needed to determine optimal care for women to address these negative psychological consequences.

Keywords: Anxiety; Depression; Neonatal Death; Perceived Stress; Perinatal Death; Pregnancy after loss; Stillbirth; Subsequent Pregnancy.

Fig. 1

Flow chart indicating the number of women screened and the number of participants in different elements of the study. The total number of participants for individual components is greater than 112 because some women participated in more than one part of the study e.g. questionnaire and hair sample

Fig. 2

Results from psychometric questionnaires. A) Cambridge Worry Score (CWS) completed at 15 weeks’ gestation, 32 weeks’ gestation and 6 weeks postnatal for all participants, B) CWS completed at the same gestations for participants who completed questionnaires at all three time points, C) GAD-7 completed at 15 weeks’ gestation, 32 weeks’ gestation and 6 weeks postnatal for all participants, D) completed at the same gestations for participants who completed questionnaires at all three time points, E) EPDS completed at 15 weeks’ gestation, 32 weeks’ gestation and 6 weeks postnatal for all participants, F) EPDS completed at the same gestations for participants who completed questionnaires at all three time points. * p<0.05, ** p<0.01, *** p<0.005, ****p<0.001

Fig. 3

Results from quality of life questionnaires. A) EQ5D score completed at 15 weeks’ gestation, 32 weeks’ gestation and 6 weeks postnatal for all participants, B) EQ5D Score completed at the same gestations for participants who completed questionnaires at all three time points, C) Visual Analogue Score (VAS) for quality of life completed at 15 weeks’ gestation, 32 weeks’ gestation and 6 weeks postnatal for all participants, D) Visual Analogue Score (VAS) for quality of life completed at the same gestations for participants who completed questionnaires at all three time points. * p<0.05, ** p<0.01, *** p<0.005, ****p<0.001

Fig. 4

Hair cortisol measurement in pg/ml demonstrating a reduction in hair cortisol levels from the 1^st through to the third trimester. * p<0.05