This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.


Screening for Perinatal Anxiety Symptoms in Obstetric Settings Is Recommended, and Proper Provider Training Is Essential

Eynav Elgavish Accortt, PhDa,*

Published: July 23, 2019

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

See related article by Fawcett et al

In this issue, Fawcett et al1 present an important and timely meta-analysis of the prevalence rates of perinatal anxiety disorders. They include articles reporting the prevalence of 1 or more of 8 common anxiety disorders in pregnant or postpartum women. A total of 2,613 records were retrieved, and anxiety disorder prevalence and potential predictor variables (eg, parity) were extracted from each of the 26 studies included. A Bayesian multivariate modeling approach estimated the prevalence and between-study heterogeneity of each disorder and the prevalence of having 1 or more disorders. Perinatal anxiety disorders were found to be more prevalent than previously thought, with 1 in 5 women meeting diagnostic criteria for at least 1 anxiety disorder. Individual disorder prevalence estimates ranged from 1.1% for posttraumatic stress disorder (PTSD) to 4.8% for specific phobia, and rates of comorbidity were high (20.7%). Substantial between-study heterogeneity was observed, suggesting that “true” prevalence varies broadly across samples.1

The prevalence of prenatal depression and anxiety ranges between 5% and 16%, and the consequences are extensive.2 In addition to negative maternal effects, research points to detrimental fetal effects and higher rates of preterm birth and low birth weight.3 Postpartum symptoms of depression and anxiety are often experienced by women prenatally and may lead to maternal suffering and parenting ineffectiveness.4 Thus, research attention to prenatal and postpartum mood and anxiety symptoms and their causes is warranted.

One strength of Fawcett and colleagues’ study is their modeling of the individual anxiety disorders using a modern Bayesian multivariate approach. This is significant, as questionnaire-based assessments of mental health conditions substantially overestimate prevalence and incidence rates. The authors also anticipated heterogeneity and therefore explored potential moderators, another important strength. Finally, the authors discussed the consequences of untreated perinatal anxiety on the growing fetus as well as the developing infant. This is important for practitioners to be aware of to ensure that they refer their patients with symptoms of perinatal anxiety to mental health providers.

Several important omissions were detected in this study. For example, the authors do not include (1) an important related condition called pregnancy-specific anxiety5; (2) the differential findings for preterm birth, low birth weight, and pregnancy-specific anxiety6; (3) the research on increased rates of anxiety in those who experience adverse pregnancy complications, adverse perinatal outcomes, or stillbirth or have babies in the neonatal intensive care unit (NICU)7-13; (4) the disparities across race and socioeconomic status14,15; (5) rigorous quality ratings; or (6) the importance of differentiating postpartum psychosis from postpartum obsessive-compulsive disorder (OCD) or postpartum depression,16 particularly as it relates to available effective treatments. These omissions are discussed in more detail below.

  1. Pregnancy-specific anxiety is not an official anxiety disorder diagnosis in the DSM. Pregnant women often have concerns about the health of their babies, labor, delivery, and the maternal role and responsibilities. These concerns are known in the literature as pregnancy-specific anxiety and have been strongly linked with adverse perinatal outcomes such as spontaneous preterm birth.5 Therefore, this important concept should be a topic of continued study in the field.
  2. In order to understand how psychosocial factors influence the complex phenomenon of preterm birth, which is one of the adverse perinatal outcomes reviewed by the authors, one must distinguish different etiologies.6 Depressive symptoms in pregnancy have been associated with fetal growth restriction, but much less often with spontaneous preterm birth. In contrast, prenatal anxiety has most often been associated with preterm birth, especially anxiety concerning one’s pregnancy.5,6 Growing evidence indicates that pregnancy-specific anxiety in expecting mothers prospectively predicts a wide range of neurodevelopmental consequences in their children, even into adolescence. Some of the outcomes linked to prenatal anxiety include impaired attention regulation and delayed mental and motor development in the first year of life,17 higher temperamental negativity in infants,18 negative behavioral reactivity to novelty in infants and 12-month mental development,19,20 behavioral and emotional problems at 4 to 7 years,21,22 decreased gray matter density on MRI scan in 6- to 9-year-olds,23 and adolescent impulsivity, externalizing, and processing speed.24,25 Thus, exploring the effects of reducing stress, anxiety, and pregnancy-specific anxiety specifically on developmental outcomes is an active and important frontier in perinatal research.
  3. Rates of anxiety and other posttraumatic stress symptoms are higher if women experience an adverse perinatal complication or outcome, such as preeclampsia or preterm birth, or have a baby in the NICU.9 For example, approximately 9% of women who experienced preeclampsia or preterm birth or had a baby in the NICU develop PTSD,10 and estimates range as high as from 28%-70% in some studies.11 This disparity is likely due to the dramatic difference in the birth and postpartum experience for these mothers. Loss of control and privacy and an inability to care for or touch her newborn can cause the NICU mother to feel incompetent. This can lead to fear and anxiety about bringing baby home and parenting in general.11 Major obstetric hemorrhage, severe preeclampsia, and intensive care unit admission have also been associated with increased postpartum PTSD symptoms.12 Women who have had a previous fetal loss, such as miscarriage and stillbirth, are especially susceptible to postpartum PTSD. According to a recent systematic review of 48 studies, PTSD or posttraumatic symptoms (PTS) occur after nonmedical (PTSD, 12.6%) and medical (PTS ranged from 41%-64%) termination of pregnancy, miscarriage (11%-68% PTS, 88% for recurrent miscarriage), perinatal loss (no prevalence rates reported), and stillbirth (21% PTSD).13 Shorter length of gestational age was also associated with an increased likelihood for diagnosis of PTS or PTSD. Demographic factors such as maternal age, gestational age, lower education, and a history of previous physical or sexual trauma are significant risk factors for the development of PTS or PTSD after loss. Prior history of mental health problems and current depression, anxiety, and perinatal grief are also risk factors.13 Therefore, inclusion of this complicated bidirectional relationship is critical so that future research can distinguish the most important risk factors and consequences involved. Specific variables would include prenatal and pregnancy-specific anxiety, pregnancy complications, and how these impact adverse birth outcomes.
  4. Disparities across race and socioeconomic status are important because rates of perinatal mood and anxiety disorders are higher in Black women, for example, and other sociodemographic risk factors play a role.14,15 A discussion on ethnicity including the racial composition of the included studies is important. This could be a limitation of the included studies (not necessarily the Fawcett analysis) but must be discussed in future work.
  5. Rigorous and informative quality ratings must be included in robust meta-analyses. For example, information on patterns could be included. Future research would benefit from the overall ratings for each included study and whether authors draw different conclusions from the moderate versus high quality studies.
  6. Clinically, it is very important to differentiate postpartum psychosis from postpartum OCD16: For example, a new mother might have thoughts of hurting her baby. The mother with OCD will be upset by these thoughts and devise intricate plans to avoid harming her baby. However, in a woman with postpartum psychosis, no such insight occurs, these thoughts are the same as any others, and immediate intervention is critical. Effective empirically based medical and psychotherapeutic treatments exist for perinatal anxiety and psychosis; however, the conditions must be screened for and properly diagnosed so that referral to care and appropriate intervention is achieved.26


Overall, this meta-analysis and its conclusions are important because perinatal anxiety (and depression) significantly affect the physical and mental well-being of the woman, her significant other(s), and her family. Aside from the limitations noted, this meta-analysis strongly supports the view that anxiety is more prevalent than depression during pregnancy and the postpartum period. Therefore, screening for prenatal and postpartum symptoms of anxiety disorders as well as pregnancy-specific anxiety is recommended in addition to depression screening. Investigating ways in which medical providers can help is critically important. The perinatal period is an opportune time for mental health screening and education because of the frequency with which women meet with health care providers. Medical providers including obstetricians, gynecologists, and maternal fetal medicine doctors and nurses, doulas, and nurse midwives must be well trained to screen for anxiety, particularly OCD symptoms, as well as depression, in order to provide proper education and referral to care. Finally, future research should focus on distinct psychosocial risk factors and establish precise pathways for how anxiety may affect the physiologic health and well-being of both mother and fetus in pregnancy and attachment, including breastfeeding, and maternal and infant health in the postpartum period.

Implications for Practice and Research


  • Anxiety is more prevalent than depression during pregnancy and the postpartum period. Therefore, screening for prenatal and postpartum symptoms of anxiety disorders as well as pregnancy-specific anxiety is recommended in addition to depression screening.
  • The perinatal period is a time when women frequently utilize health care. Therefore, to detect perinatal mental disorders, medical providers must be trained in anxiety screening to provide proper education and referral to care.
  • Future research should focus on distinct psychosocial risk factors and establish precise pathways for how anxiety may affect the physiologic health and well-being of both mother and fetus in pregnancy and attachment and infant health in the postpartum period.

Published online: July 23, 2019.

Potential conflicts of interest: None.


1.Fawcett EJ, Fairbrother N, Cox ML, et al. The prevalence of anxiety disorders during pregnancy and the postpartum period: a multivariate Bayesian meta-analysis. J Clin Psychiatry. 2019;80(4):18r12527.

2.Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry. 2012;25(2):141-148. PubMed CrossRef

3.Grote NK, Bridge JA, Gavin AR, et al. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012-1024. PubMed CrossRef

4.Burt VK, Stein K. Epidemiology of depression throughout the female life cycle. J Clin Psychiatry. 2002;63(suppl 7):9-15. PubMed

5.Guardino CM, Dunkel Schetter C. Understanding pregnancy anxiety: concepts, correlates, and consequences. Zero Three. 2014;34:12-21.

6.Accortt EE, Cheadle AC, Dunkel Schetter C. Prenatal depression and adverse birth outcomes: an updated systematic review. Matern Child Health J. 2015;19(6):1306-1337. PubMed CrossRef

7.Kurki T, Hiilesmaa V, Raitasalo R, et al. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol. 2000;95(4):487-490. PubMed

8.Qiu C, Williams MA, Calderon-Margalit R, et al. Preeclampsia risk in relation to maternal mood and anxiety disorders diagnosed before or during early pregnancy. Am J Hypertens. 2009;22(4):397-402. PubMed CrossRef

9.Tahirkheli NN, Cherry AS, Tackett AP, et al. Postpartum depression on the neonatal intensive care unit: current perspectives. Int J Womens Health. 2014;6:975-987. PubMed

10.Beck CT, Gable RK, Sakala C, et al. Posttraumatic stress disorder in new mothers: results from a two-stage US national survey. Birth. 2011;38(3):216-227. PubMed CrossRef

11.Lefkowitz DS, Baxt C, Evans JR. Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive Care Unit (NICU). J Clin Psychol Med Settings. 2010;17(3):230-237. PubMed CrossRef

12.Furuta M, Sandall J, Cooper D, et al. The relationship between severe maternal morbidity and psychological health symptoms at 6-8 weeks postpartum: a prospective cohort study in one English maternity unit. BMC Pregnancy Childbirth. 2014;14(1):133. PubMed CrossRef

13.DaugirdaitÄ— V, van den Akker O, Purewal S. Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review. J Pregnancy. 2015;2015:646345. PubMed CrossRef

14.Segre L, O’ Hara M, Losch M. Race/ethnicity and perinatal depressed mood. J Reprod Infant Psychol. 2006;24(2):99-106. CrossRef

15.Orr ST, Blazer DG, James SA. Racial disparities in elevated prenatal depressive symptoms among black and white women in eastern North Carolina. Ann Epidemiol. 2006;16(6):463-468. PubMed CrossRef

16.Sharma V, Sommerdyk C. Obsessive-compulsive disorder in the postpartum period: diagnosis, differential diagnosis and management. Womens Health (Lond). 2015;11(4):543-552. PubMed CrossRef

17.Huizink AC, de Medina PG, Mulder EJ, et al. Psychological measures of prenatal stress as predictors of infant temperament. J Am Acad Child Adolesc Psychiatry. 2002;41(9):1078-1085. PubMed CrossRef

18.Bergman K, Sarkar P, O’ Connor TG, et al. Maternal stress during pregnancy predicts cognitive ability and fearfulness in infancy. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1454-1463. PubMed CrossRef

19.Davis EP, Sandman CA. The timing of prenatal exposure to maternal cortisol and psychosocial stress is associated with human infant cognitive development. Child Dev. 2010;81(1):131-148. PubMed CrossRef

20.Davis E, Snidman N, Wadhwa P, et al. Prenatal maternal anxiety and depression predict negative behavioral reactivity in infancy. Infancy. 2004;6(3):319-331. CrossRef

21.O’ Connor TG, Heron J, Golding J, et al. Maternal antenatal anxiety and children’s behavioural/emotional problems at 4 years: report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry. 2002;180(6):502-508. PubMed CrossRef

22.O’ Connor TG, Heron J, Golding J, et al; ALSPAC Study Team. Maternal antenatal anxiety and behavioural/emotional problems in children: a test of a programming hypothesis. J Child Psychol Psychiatry. 2003;44(7):1025-1036. PubMed CrossRef

23.Buss C, Davis EP, Muftuler LT, et al. High pregnancy anxiety during mid-gestation is associated with decreased gray matter density in 6-9-year-old children. Psychoneuroendocrinology. 2010;35(1):141-153. PubMed CrossRef

24.Mennes M, Stiers P, Lagae L, et al. Long-term cognitive sequelae of antenatal maternal anxiety: involvement of the orbitofrontal cortex. Neurosci Biobehav Rev. 2006;30(8):1078-1086. PubMed CrossRef

25.Van den Bergh BR, Mulder EJ, Mennes M, et al. Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms: a review. Neurosci Biobehav Rev. 2005;29(2):237-258. PubMed CrossRef

26.Accortt EE, Wong MS. It is time for routine screening for perinatal mood and anxiety disorders in obstetrics and gynecology settings. Obstet Gynecol Surv. 2017;72(9):553-568. PubMed CrossRef

aDepartment of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California

*Corresponding author: Eynav Elgavish Accortt, PhD, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, 8635 W 3rd St, 280 West Tower, Los Angeles, CA 90048 (

J Clin Psychiatry 2019;80(4):19com12939

To cite: Accortt EE. Screening for perinatal anxiety symptoms in obstetric settings is recommended, and proper provider training is essential. J Clin Psychiatry. 2019;80(4):19com12939.

To share:

Related Articles

Volume: 80

Quick Links: