Maternal anxiety related to prenatal

Maternal Anxiety Related to Prenatal
Diagnoses of Fetal Anomalies That
Require Surgery
Q9Abigail B. Wilpers, Holly Powell Kennedy, Diane Wall, Marjorie Funk, and Mert Ozan Bahtiyar
ABSTRACT
Objectives: To investigate maternal anxiety in women with pregnancies complicated by fetal anomalies that require
surgery.
Design: Prospective comparison pilot study.
Setting: A fetal care center in a Northeastern U.S. academic medical center.
Participants: Women in their second or early third trimesters of pregnancy; 19 with pregnancies complicated by fetal
anomalies and 25 without.
Methods: After ultrasonography, all participants completed the Spielberger State–Trait Anxiety Inventory and a
sociodemographic questionnaire. Participants with pregnancies complicated by fetal anomalies also answered
questions about the causes of their anxiety, their awareness of the nurse care coordinator service, and desired
methods of emotional support. Obstetric and mental health history data were abstracted from the medical records of
both groups.
Results: Participants with pregnancies complicated by fetal anomalies had greater mean state anxiety scores than
those without (43.58 vs. 29.08, p ¼ .002). Maternal age was positively correlated with the state anxiety in women with
fetuses with anomalies (r ¼ 0.59, p ¼ .008). Participants with histories of mental health issues had greater mean trait
anxiety scores than those without (39.2 vs. 32.2, p ¼ .048). Most participants (68%) reported that knowledge of the
fetal care center’s nurse care coordinator decreased their anxiety. Participants wanted the opportunity to speak with
families who had similar experiences as a source of emotional support.
Conclusion: Older maternal age may be a risk factor for anxiety in this population. Knowledge of the fetal care center
nurse care coordinator service may have a positive effect and should be studied further.
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2017.02.001
Accepted February 2017
An increasing number of fetal anomalies is
being detected and managed during preg-
nancy, in part because of advancements in
ultrasonography and prenatal screening. Some of
the most prevalent diagnoses are nonlethal fetal
anomalies that can be corrected or treated
surgically after birth (Parker et al., 2010). These
newborns often undergo surgery within the first
few days of life. The diagnosis and management
processes for surgically treatable fetal anomalies
are associated with significant maternal anxiety
(Aite et al., 2006; Leithner et al., 2004; Rosenberg
et al., 2010; Skari et al., 2006). However, women
whose pregnancies are complicated by these
fetal anomalies are often excluded from studies
on the emotional effects of prenatal diagnoses,
usually because of their more favorable
prognoses compared with lethal and chromo-
somal conditions. The risk for this population
cannot be overlooked, because negative out-
comes are associated with maternal anxiety in
pregnancy. These outcomes can be severe,
including preterm birth, newborns who are small
for gestational age, and childhood neuro-
developmental delays (Blair, Glynn, Sandman, &
Davis, 2011; Kramer et al., 2009). Furthermore,
evidence suggests that pregnancy-related anxi-
ety is more strongly associated with preterm birth
and adverse child outcomes than general anxiety
and depression (Lobel et al., 2008).
Multidisciplinary prenatal care through a fetal
care center is the recommended standard prac-
tice for women whose pregnancies are
The authors report no con-
flict of interest or relevant
financial relationships.
Correspondence
Abigail B. Wilpers, MSN,
WHNP-BC, Yale School of
Nursing, Yale West
Campus, P.O. Box 27399,
West Haven, CT 06516-
7399.
abigail.wilpers@yale.edu
Keywords
fetal care center
fetal diagnosis
fetal therapy
fetal treatment center
high-risk pregnancy
maternal anxiety
maternal experience
nurse care coordinator
surgical fetal anomaly
Abigail B. Wilpers, MSN,
WHNP-BC, is a doctoral
student in the Yale School of
Nursing, West Haven, CT.
Holly Powell Kennedy,
PhD, CNM, FACNM,
FAAN, is the Executive
Deputy Dean and Helen
Varney Professor of
Midwifery, Yale School of
(Continued)
ª 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses.
Published by Elsevier Inc. All rights reserved.
http://jognn.org 1
R E S E A R C H
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
FLA 5.4.0 DTD Š JOGN202_proof Š 5 April 2017 Š 4:38 pm Š ce

complicated by fetal anomalies (American
College of Obstetricians and Gynecologists
Committee on Ethics & American Academy of
Pediatrics Committee on Bioethics, 2011). Coor-
dinated multidisciplinary care and consultations
by maternal–fetal medicine specialists, neo-
natologists, and pediatric medical and surgical
subspecialists have been shown to decrease
maternal anxiety associated with the diagnosis of
a fetal anomaly that requires surgery (Aite et al.,
2002; Kemp, Davenport, & Pernet, 1998). In
some centers, further steps to decrease maternal
anxiety have been taken by integrating mental
health professionals and emotional support
services into the prenatal care team (e.g., psy-
chologists, religious services, social workers,
palliative care and/or child life specialists). The
use of these interventions has shown to signifi-
cantly decrease maternal anxiety, and they are
widely recommended (Aite et al., 2002; Gorayeb,
Gorayeb, Berezowski, & Duarte, 2013; Kemp
et al., 1998; Langer & Ringler, 1989; Statham,
Solomou, & Chitty, 2000).
Although nurses provide care for women during
pregnancy and the postnatal period, their role in
the provision of psychological support to women
and families in fetal care centers has not been
well studied. At the center of the treatment team is
the care coordinator, usually a nurse with an
obstetric or pediatric background. This role has
been described as “the linchpin” (Besuner &
Imhoff, 2007), “the glue” (Moise, 2014), and “theQ1
fulcrum” (Chock, Davis, & Hintz, 2015) in the care
of women during fetal diagnosis and treatment.
A key aspect of the coordinator’s role involves
psychosocial support, and this individual often
serves as the primary contact for women and
their families during the prenatal period. The
nurse coordinator must assess emotional well-
being and advocate for a woman’s necessary
support (Besuner & Imhoff, 2007; Moise, Kugler,
& Jones, 2012). The limited resources of many
health care systems may preclude mental health
services for all women enrolled at fetal care
centers. In many cases, the nurse coordinator
may be the primary emotional support for women.
In these instances, it is important to assess
which women are at increased riskQ2 so that
resource-intensive interventions can be targeted.
Establishing risk factors can help members of fetal
care center teams identify women in need of
additional psychosocial support. Staff at the cen-
ters can develop patient-directed care by
assessing which support methods women would
be most likely to use to decrease their anxiety.
Knowledge of risk factors for anxiety could
contribute to targeting those in need of interven-
tion, whereas factors associated with lower anxiety
and feedback from participants could be used to
inform development of future interventions.
The objective of this pilot study was to investigate
maternal anxiety in pregnancies complicated by
fetal anomalies that require future surgery. This
was done through (a) comparison of anxiety
levels in women with and without pregnancies
complicated by fetal anomalies that require
surgery, (b) examination of the relationships
among maternal anxiety and sociodemographic
and clinical characteristics, (c) investigation of
how information about the nurse care coordinator
affected maternal anxiety, and (d) description of
the women’s interest in potential methods of
emotional support.
Methods
Design and Sample
We conducted a prospective comparison pilot
study at a fetal care center in a Northeastern U.S.
academic medical center. The University’s Q3insti-
tutional review board approved the study. Women
were recruited through clinician referral in the
fetal care center. Two groups of women who
presented at the center for second trimester
ultrasonography were eligible for the study. The
first group included women with pregnancies
complicated by a nonlethal, major structural fetal
malformation that would require corrective
surgery within the child’s first year of life. These
women were not approached at the time of
diagnosis but at a follow-up visit to the center
once the decision had been made to continue the
pregnancy and transfer their care to the center.
Women whose fetuses had primary brain anom-
alies were excluded because of the greater like-
lihood of a residual impairment and poorer
prognosis than most anomalies that require
surgery. The second group included women who
presented for routine ultrasonographic screening
who had no fetal or obstetric complications.
These women served as a control group and
were approached after physician confirmation of
normal ultrasonography results. Eligibility was
limited to women who spoke English and were
older than 18 years of age.
Diane Wall, MSN, RN,
CNE, is Program
Coordinator of the Fetal
Care Center, Yale New
Haven Hospital, New
Haven, CT.
Marjorie Funk, PhD, RN,
FAHA, FAAN, is the Helen
Porter Jayne and Martha
Prosser Jayne Professor of
Nursing, Yale School of
Mert Ozan Bahtiyar, MD, is
an associate professor of
Obstetrics, Gynecology, and
Reproductive Sciences, Yale
School of Medicine and the
Director of the Fetal Care
Center, Yale New Haven
Hospital, New Haven, CT.
Evidence suggests that pregnancy-related anxiety is more
strongly associated with preterm birth and adverse child
outcomes than general anxiety and depression.
Maternal Anxiety and Fetal Anomalies Requiring SurgeryR E S E A R C H
2 JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2017.02.001 http://jognn.org
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224

Fetal anomalies that require surgical correction
are usually detected after a routine anatomic
ultrasonographic examination around 18 to
20 weeks gestation. All participants were enrolled
during the second trimester, with the exception of
one participant who had completed the first week
of her third trimester. The second trimester is the
period in pregnancy least likely to be associated
with anxiety (Rofe, Blittner, & Lewin, 1993). Thus,
for women whose pregnancies are complicated
by fetal anomalies, anxiety at this time may be
more likely related to the anomaly diagnosis
versus the common pregnancy anxieties seen in
the first and third trimesters.
Measures
Anxiety levels were measured using the Spiel-
berger State–Trait Anxiety Inventory (STAI), a
self-rating instrument for the assessment of the
current (state) and intrinsic (trait) level of anxiety.
The construct validity of the scale is shown
through substantial evidence. Researchers sug-
gested that the STAI is the best instrument to
measure prenatal anxiety symptomatology, with
high validity and reliability in pregnant pop-
ulations (Nast, Bolter, Meinlschmidt, &
Hellhammer, 2013; Spielberger and Gorsuch,
1983). STAI scores of state and trait anxiety
range from 20 to 80, with greater scores indi-
cating greater levels of anxiety. Women who
score greater than 40 on the STAI have been
considered highly anxious (Bayrampour,
McDonald, & Tough, 2015; Evans, Myers, &
Monk, 2008; Giardinelli et al., 2012; Grant,
McMahon, & Austin, 2008).
Participants whose pregnancies were compli-
cated by fetal anomalies were also assessed for
pregnancy-related anxiety. There is a lack of
standardization among instruments to measure
pregnancy-related anxiety. Thus, we asked
participants directly, If you feel that you are expe-
riencing anxiety at this time in your life, please list
the three things that you feel contribute most to
your anxiety. We used the dimensions of preg-
nancy anxiety described by Bayrampour and
colleagues (2016) to guide a content analysis of
the written responses. Sociodemographic data
were collected from both groups. A data collection
tool was used to abstract relevant clinical infor-
mation on obstetric and mental health history from
the medical records of both groups. Clinical infor-
mation was used to categorize the fetal diagnoses
as major or minor based on the criteria established
by Titapant and Chuenwattana (2015), in which
major diagnoses had a greater risk of a lasting
impairment, and minor diagnoses were less se-
vere, with little to no functional significance.
Participants whose fetuses had anomalies were
also asked about their knowledge of the fetal care
center’s nurse care coordinator and how their
anxiety was affected by receipt of this informa-
tion. The goal of the center is to inform women of
this service at the time of diagnosis and if a
transfer of care is likely. Participants were first
asked if they had been informed that there was a
nurse who would be coordinating their care
throughout the pregnancy. This was followed up
with the question, Did information about the nurse
care coordinator make you feel less anxious? For
both questions participants could select yes, no,
or not sure.
Finally, participants were presented with a list of
emotional support services and asked to select
those services they would be interested in if they
were offered by the center. The list included a
support group at the fetal care center, the
opportunity to speak with families who have had a
similar experience, and mental health resources
(at the care center or a referral to someone
outside the care center). Data were collected at
the center by the first author (A.B.W.), and no
further participation was required. All data were
de-identified.
Associations
Independent t tests and chi-square tests were
used to determine if the groups of participants
with and without pregnancies complicated by
fetal anomalies were equal in their sociodemo-
graphic and clinical characteristics. A two-tailed
independent t test was used to compare anxiety
state and trait levels between the groups with and
without pregnancies complicated by fetal anom-
alies that require surgery. Chi-square tests were
used to compare the proportion of participants
with high anxiety (state score >40) in each group.
To analyze pregnancy-related anxiety, the first
two authors (A.B.W. and H.P.K.) independently
conducted a content analysis of all 41 answers
and achieved 98% consensus. Two-tailed inde-
pendent t test, one-way analysis of variance, and
Pearson’s correlation were used to investigate the
association of sociodemographic and clinical
factors with maternal state and trait anxiety for all
participants. To assess the influence of aware-
ness of the nurse care coordinator, a two-tailed
independent t test was used to compare anxiety
scores of the participants who reported
Wilpers, A. B., Kennedy, H. P., Wall, D., Funk, M., and Bahtiyar, M. O. R E S E A R C H
JOGNN 2017; Vol. -, Issue - 3
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336

decreased anxiety due to knowledge of the care
coordinator with those who reported that infor-
mation about the care coordinator did not influ-
ence their anxiety. Interest in potential emotional
support services was evaluated by total number
of selections for each choice. All statistical ana-
lyses were conducted using StatPlus (AnalystSoft
Inc., Walnut, CA).
Results
Participants were recruited between August 2015
and February 2016. Of the 48 women who were
approached, 44 consented and completed the
questionnaires, 19 with fetuses with anomalies
and 25 without. Four women without fetal anom-
alies declined to participate because of time
constraints. All women with fetuses with anoma-
lies who were approached agreed to participate.
This was a small pilot study; therefore, no a priori
power analysis was done. Participants with and
without pregnancies complicated by fetal anom-
alies were comparable on all sociodemographic
and clinical characteristics (see Table 1). The
variety of fetal diagnoses and the distribution
across severity groups are shown in Table 2.
ScoresQ4 are reported as mean Æ standard
deviation.
Participants with pregnancies complicated by fetal
anomalies had a greater mean state anxiety score
than those without (43Q5 .58 vs. 29.08, p ¼ .002; see
Table 3). The mean trait anxiety scores did not
differ between the two groups: 33.74 Æ 8.09 for
participants with fetuses with anomalies versus
34.84 Æ 9.72 for those without fetal or obstetric
complications (p ¼ .68). Ten of the 19 participants
(53%) whose fetuses had anomalies had state
anxiety scores greater than the established cutoff
of 40, which suggested greater anxiety. Only 3 of
the 25 participants (12%) without current obstetric
or fetal complications had state anxiety scores
greater than 40 (p ¼ .003).
Older maternal age was positively associated with
greater state anxiety scores (r ¼ 0.59, p ¼ .008;
see Figure 1) This relationship was not seen in the
control group. There was no relationship between
age and trait anxiety in either group. No other
sociodemographic or clinical characteristics
investigated were significantly associated with
state anxiety. However, falling just short of signifi-
cance (p ¼ .052), participants with pregnancies
complicated by fetal anomalies who also had prior
pregnancy complications (n ¼ 5) trended toward
greater mean state scores than those in the
fetal anomaly group who did not have prior preg-
nancy complications (n ¼ 14, 53.8 Æ 16.3 vs.
37.5 Æ 14.9). Another trend that did not reach
significance showed that participants with severe
diagnoses had greater state anxiety scores
than those with minor diagnoses (48.5 Æ 17.5 vs.
38.1 Æ 15.6, p ¼ 0.19; see Table 3).
Only one association was found between trait
anxiety and sociodemographic or clinical char-
acteristics in either group. Participants whose
pregnancies were complicated by fetal anoma-
lies and had histories of mental health diagnoses
had greater mean trait anxiety scores than the
control group (39.2 Æ 4.2 vs. 32.2 Æ 8.6, p ¼ .048;
see Table 3).
When assessing pregnancy-related anxiety in
participants whose pregnancies were complicated
by fetal anomalies, three women declined and
stated that they did not feel any anxiety. All three of
these participants had diagnoses categorized as
minor. One participant declined without stating a
reason. Of the 41 responses, 39 were pregnancy-
related, and of these, 32 were specifically related
to the fetal complication. Descriptors included
worried about my baby needing surgery, finances
to support baby with special needs, and anxious
about my baby’s prognosis: quality of life. Thus,
high state anxiety was determined to be
pregnancy-related anxiety and, more specifically,
related to the fetal anomaly.
Most participants (84%) were aware of the fetal
care center nurse care coordinator and her role.
Most (68%) reported that being informed of the
nurse care coordinator had decreased their
anxiety. Participants who reported feeling that the
information about the nurse care coordinator
decreased their anxiety had a lower mean state
anxiety score than those who denied or were
unsure that this information decreased their
anxiety (39.61 Æ 16.32 vs. 52.15 Æ 16.67), but
this difference was not statistically significant
(p ¼ .16). Finally, when asked about what
potential emotional support services they would
be interested in if offered by the fetal care center,
10 participants (53%) expressed interest in a
support group, and 15 participants (79%) were
interested in speaking with a family who had a
similar experience to theirs. Only one participant
Older maternal age was positively associated with greater
state anxiety scores.
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448

(5%) expressed an interest in mental health re-
sources (within the fetal care center and/or an
outside referral).
Discussion
In this pilot study, we sought to better understand
maternal anxiety in pregnancies complicated by
fetal anomalies that require neonatal surgery. Our
ﬁndings indicate that these women are at risk for
increased anxiety, and 53% of participants in our
study scored 40 or greater on the STAI during
pregnancy. In previous studies, women with STAI
scores at this level also met clinical criteria for
anxiety disorders (Grant et al., 2008). Through our
Table 1: Sociodemographic and Clinical Characteristics of Women With and Without Fetal
Anomalies Q6 Q7
Variable
Fetal Anomaly Group (n ¼ 19) Control Group (n ¼ 25)
pn (%) or Mean Æ SD n (%) or Mean Æ SD
Maternal age in years 28.89 Æ 7 31.12 Æ 7.8 .33
Gestational age in weeks 23.98 Æ 3.16 18.65 Æ 1.1 4.96
Race
White 10 (53) 12 (48)
Hispanic 5 (26) 6 (24) .93
Black or African American 3 (16) 6 (24)
Asian or Paciﬁc Islander 1 (5) 1 (4)
Level of education
Higher education 16 (84) 20 (80) .72
High school/high school equivalency 3 (16) 5 (20)
Employment
Employed 15 (79) 16 (64) .28
Unemployed 4 (21) 9 (36)
Marital Status
Married 14 (74) 17 (68) .08
Relationship 3 (16) 5 (20)
Single 2 (10) 1 (4)
Annual household income
#$50,000 7 (37) 11 (44) 0.63
>$50,000 12 (63) 14 (56)
History of pregnancy complicationa
Yes 7 (37) 8 (32) .74
No 12 (63) 17 (68)
History of mental health conditionb
Yes 5 (26) 5 (20) .62
No 14 (74) 20 (80)
Parity
Nulliparous 8 (42) 10 (40) .89
Multiparous 11 (58) 15 (60)
a
Pregnancy complications included prior ectopic pregnancy, preterm birth, postpartum hemorrhage, gestational diabetes, miscarriage,
fetal anomaly, and cesarean birth. b
Mental health history included medical record data and patient report. Conditions included anxiety,
depression, postpartum depression, and borderline personality disorder.
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560

findings we have also helped identify character-
istics that may be useful to target women in need
of more emotional support: older age and a his-
tory of mental health conditions.
The relationship between mental health history
and maternal perinatal anxiety has been well
documented (Hunfeld et al., 1993). However, the
positive association between age and maternal
state anxiety scores is a unique finding and may
be distinctive to women with pregnancies
complicated by a fetal anomaly. Most in-
vestigations of maternal age and anxiety in
pregnancy find younger age to be a risk factor
(Lee et al., 2007; Rezaee & Framarzi, 2014).
However, those studies did not focus on women
with pregnancy complications. Limited research
has been done to examine age and anxiety in
women who continue pregnancies complicated
by fetal anomalies. We could identify only one
previous study in which the researchers showed
that advanced maternal age was associated with
increased anxiety in this population (Horsch et al.,
2013). The lack of data may be related to the fact
that older women are more likely to terminate a
pregnancy when serious anomalies are present
(Schechtman, Gray, Baty, & Rothman, 2002). The
reasons for these findings have not been clari-
fied, and investigation of this phenomenon may
illuminate the apparent relationship between age
and maternal anxiety related to fetal anomalies.
Statistical trends found in this pilot study that may
have reached significance with a larger sample
size included the relationship of anxiety to a his-
tory of pregnancy complications and a more se-
vere diagnosis. These trends have been
observed in previous research (Forray, Mayes,
Magriples, & Epperson, 2009; Titapant &
Chuenwattana, 2015).
Most participants reported that knowledge of the
fetal care center’s nurse care coordinator
decreased their anxiety. Although these partici-
pants did have lower mean state anxiety scores,
the difference was not statistically significant,
most likely because of the small sample size and
lack of power. However, it is suggested in the
participants’ feedback that being informed of the
nurse care coordinator influenced their perceived
anxiety, which indicates a potential benefit for
maternal mental health. Further assessment of
the fetal care center nurse care coordinator role
may provide valuable information to improve care
for women and their families.
When given options for emotional support, most
participants were primarily interested in speaking
with other families who have had similar experi-
ences. A little more than half of the participants
also showed interest in support groups at the fetal
care center, but only one was interested in mental
health resources. This could be due to a stigma
associated with needing professional mental
health services that may not be as linked with less
“medical” methods of emotional support, such as
support groups and speaking with other families.
Understanding women’s perceptions of mental
health and emotional support services is key to
the implemention of effective interventions.
This pilot study was limited by its small sample
size, which may not have provided the power to
detect differences across groups. Some socio-
demographic categories had very small
numbers, which prevented between group com-
parisons. In addition, findings may not be repre-
sentative of the greater population of women
whose pregnancies are complicated by fetal
anomalies that require surgery. We also did not
control for current or past mental health di-
agnoses, or the use of reproductive assisted
technologies, which could confound our findings.
Table 2: Conditions of the Fetuses of
Women With Fetal Anomalies
Diagnosis n %
Minor anomalies
Gastroschisis 4 21.0
Congenital cystic adenomatoid
malformation
3 15.8
Pulmonary stenosis 2 10.5
Major anomalies
Hypoplastic right heart syndrome 2 10.5
Sacral myelomeningocele 2 10.5
Complete atrioventricular canal defect 2 10.5
Congenital diaphragmatic hernia 1 5.3
Hemivertebrae 1 5.3
Hypoplastic left heart syndrome 1 5.3
Sacrococcygeal teratoma 1 5.3
Most participants reported that being informed about the
availability of a nurse care coordinator decreased their
anxiety.
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672

Finally, the possible connections of fetal anoma-
lies, maternal anxiety, and subsequent maternal–
infant bonding or postpartum depression were
beyond the scope of this study, but these should
be explored in the future.
Implications
The ﬁndings from this pilot study are supportive of
the potential presence of risk factors that may be
used to identify women in greater need of
emotional support during pregnancies compli-
cated by fetal anomalies that require neonatal
surgery. Participants’ comments suggested that
they might not use professional mental health
services, even if resources were available. A
patient-centered and cost-effective alternative
would be to focus on interventions that allow
women to speak with other families who have had
similar experiences. The nurse coordinator is
central in the development and implementation of
these interventions and, as this study has rein-
forced, plays a key role in decreasing maternal
anxiety. If knowledge of the nurse coordinator has
a positive effect on women, then providers should
inform women about this service as soon as
possible. Referring practitioners should also
receive education about the nurse coordinator
role. This will allow obstetricians, midwives, family
physicians, and advanced practice nurses to
facilitate continuity of care as women are trans-
ferred to fetal care centers. Health care providers
should emphasize the beneﬁts of the nurse
coordinator service and encourage women to
discuss their emotional support needs. Re-
searchers should examine potential models of
nursing care for this population and the effect on
women’s experiences during this challenging
time in their lives.
Conclusion
Women whose pregnancies are complicated by a
fetal anomaly that requires neonatal surgery are
at risk for anxiety that is associated with negative
Table 3: Sociodemographic and Clinical Associations with STAI Scores in Women With
and Without Fetal Anomalies
Variable
Anomaly Group (n ¼ 19),
Mean Æ SD p
Control Group (n ¼ 25),
Mean Æ SD p
State score 43.6 Æ 17.0 29.1 Æ 8.5 .002
Trait score 33.7 Æ 8.1 34.8 Æ 9.7 .68
Parity Nulliparous Multiparous Nulliparous Multiparous
State score 36.2 Æ 16.5 48.9 Æ 16.1 .12 27.9 Æ 6.1 29.8 Æ 9.9 .41
Trait score 32.7 Æ 8.8 34.4 Æ 7.9 .67 32.7 Æ 7.9 36.2 Æ 10.7 .35
Past pregnancy complication Pos History Neg History Pos History Neg History
State score 53.8 Æ 16.3 37.5 Æ 14.9 .052 Q830.8 Æ 8.4 28.2 Æ 8.6 .48
Trait score 33 Æ 4.3 34.1 Æ 9.8 .91 36.2 Æ 10.5 34.2 Æ 9.5 .64
Mental health history Pos History Neg History Pos History Neg History
State score 52.6 Æ 20.1 40.3 Æ 15.3 .27 28.2 Æ 3.1 28.9 Æ 9.3 .81
Trait score 39.2 Æ 4.2 32.2 Æ 8.6 .048 39.6 Æ 6.6 33.6 Æ10.1 .14
Fetal diagnosis severitya
Major Minor
State Score 48.5 Æ 17.5 38.1 Æ 15.6 .19
Note. Neg ¼ negative; Pos ¼ positive.
a
See Table 2.
print&web4C=FPOprint&web4C=FPOprint&web4C=FPO
Figure 1. Maternal age was positively associated with state
anxiety score in women with pregnancies complicated by
fetal anomalies. STAI ¼ State–Trait Anxiety Index.
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
784

maternal and child outcomes. Fetal care centers,
with their multidisciplinary holistic approach to
prenatal care, provide an opportune environment
to examine these concerns. Nurses are central to
the advancement of research and clinical care in
this field.
REFERENCES
Aite, L., Trucchi, A., Nahom, A., Spina, V., Bilancioni, E., & Bagolan, P.
(2002). Multidisciplinary management of fetal surgical anoma-
lies: The impact on maternal anxiety. European Journal Of
Pediatric Surgery, 12, 90–94. http://dx.doi.org/10.1055/s-2002-
30164
Aite, L., Zaccara, A., Nahom, A., Trucchi, A., Iacobelli, B., & Bagolan,
P. (2006). Mothers’ adaptation to antenatal diagnosis of surgi-
cally correctable anomalies. Early Human Development, 82,
649–653. http://dx.doi.org/10.1016/j.earlhumdev.2005.12.010
American College of Obstetricians and Gynecologists Committee on
Ethics & American Academy of Pediatrics Committee on
Bioethics. (2011). Committee opinion no. 501: Maternal–fetal
intervention and fetal care centers. Obstetics & Gynecology, 118,
405–410. http://dx.doi.org/10.1097/AOG.0b013e31822c99af
Bayrampour, H., Ali, E., McNeil, D. A., Benzies, K., MacQueen, G., &
Tough, S. (2016). Pregnancy-related anxiety: A concept anal-
ysis. International Journal of Nursing Studies, 55, 115–130.
http://dx.doi.org/10.1016/j.ijnurstu.2015.10.023
Bayrampour, H., McDonald, S., & Tough, S. (2015). Risk factors of
transient and persistent anxiety during pregnancy. Midwifery,
31, 582–589. http://dx.doi.org/10.1016/j.midw.2015.02.009
Besuner, P., & Imhoff, S. (2007). The fetal patient: Coordinated care for
families. Newborn and Infant Nursing Reviews, 7, 211–215.
http://dx.doi.org/10.1053/j.nainr.2007.09.010
Blair, M. M., Glynn, L. M., Sandman, C. A., & Davis, E. P. (2011).
Prenatal maternal anxiety and early childhood temperament.
Stress, 14, 644–651. http://dx.doi.org/10.3109/10253890.2011.
594121
Chock, V. Y., Davis, A. S., & Hintz, S. R. (2015). The roles and
responsibilities of the neonatologist in complex fetal medicine:
Providing a continuum of care. NeoReviews, 16, e9–e15. http://
dx.doi.org/10.1055/s-0034-1371709
Evans, L. M., Myers, M. M., & Monk, C. (2008). Pregnant women’s
cortisol is elevated with anxiety and depression—But only when
comorbid. Archives of Women’s Mental Health, 11, 239–248.
http://dx.doi.org/10.1007/s00737-008-0019-4
Forray, A., Mayes, L. C., Magriples, U., & Epperson, C. N. (2009).
Prevalence of post-traumatic stress disorder in pregnant
women with prior pregnancy complications. Journal of
Maternal-Fetal and Neonatal Medicine, 22, 522–527. http://dx.
doi.org/10.1080/14767050902801686
Giardinelli, L., Innocenti, A., Benni, L., Stefanini, M. C., Lino, G.,
Lunardi, C., ., Faravelli, C. (2012). Depression and anxiety in
perinatal period: Prevalence and risk factors in an Italian
sample. Archives of Women’s Mental Health, 15, 21–30. http://
dx.doi.org/10.1007/s00737-011-0249-8
Gorayeb, R. P., Gorayeb, R., Berezowski, A. T., & Duarte, G. (2013).
Effectiveness of psychological intervention for treating symp-
toms of anxiety and depression among pregnant women
diagnosed with fetal malformation. International Journal of
Gynecology & Obstetrics, 121, 123–126. http://dx.doi.org/
10.1016/j.ijgo.2012.12.013
Grant, K. A., McMahon, C., & Austin, M. P. (2008). Maternal anxiety
during the transition to parenthood: A prospective study.
Journal of Affective Disorders, 108, 101–111. http://dx.doi.org/
10.1016/j.jad.2007.10.002
Horsch, A., Brooks, C., & Fletcher, H. (2013). Maternal coping,
appraisals and adjustment following diagnosis of fetal anomaly.
Prenatal Diagnosis, 33, 1137–1145. http://dx.doi.org/10.1002/
pd.4207
Hunfeld, J. A., Wladimiroff, J. W., Passchier, J., Venema-Van Uden, M.
U., Frets, P. G., & Verhage, F. (1993). Emotional reactions in
women in late pregnancy (24 weeks or longer) following the
ultrasound diagnosis of a severe or lethal fetal malformation.
Prenatal Diagnosis, 13, 603–612. http://dx.doi.org/10.1002/
pd.1970130711
Kemp, J., Davenport, M., & Pernet, A. (1998). Antenatally diagnosed
surgical anomalies: The psychological effect of parental ante-
natal counseling. Journal of Pediatric Surgery, 33, 1376–1379.
http://dx.doi.org/10.1016/S0022-3468(98)90011-2
Kramer, M. S., Lydon, J., Seguin, L., Goulet, L., Kahn, S. R., McNa-
mara, H., … Platt, R. W. (2009). Stress pathways to sponta-
neous preterm birth: The role of stressors, psychological
distress, and stress hormones. American Journal of Epidemi-
ology, 169, 1319–1326. http://dx.doi.org/10.1093/aje/kwp061
Langer, M., & Ringler, M. (1989). Prospective counselling after
prenatal diagnosis of fetal malformations: Interventions and
parental reactions. Acta Obstetricia et Gynecologica Scandi-
navica, 68, 323–329. http://dx.doi.org/10.3109/0001634890
9028667
Lee, A. M., Lam, S. K., Sze Mun Lau, S. M., Chong, C. S., Chui, H. W., &
Fong,D.Y.(2007).Prevalence,course,andriskfactorsforantenatal
anxiety and depression. Obstetics and Gynecology, 110, 1102–
1112. http://dx.doi.org/10.1097/01.AOG.0000287065.59491.70
Leithner, K., Maar, A., Fischer-Kern, M., Hilger, E., Loffler-Stastka, H., &
Ponocny-Seliger, E. (2004). Affective state of women following a
prenatal diagnosis: Predictors of a negative psychological
outcome. Ultrasound in Obstetrics and Gynecology, 23, 240–
246. http://dx.doi.org/10.1002/uog.978
Lobel, M., Cannella, D. L., Graham, J. E., DeVincent, C., Schneider, J.,
& Meyer, B. A. (2008). Pregnancy-specific stress, prenatal
health behaviors, and birth outcomes. Health Psychology, 27,
604–615. http://dx.doi.org/10.1037/a0013242
Moise, K. J., Jr. (2014). The history of fetal therapy. American Journal
of Perinatology, 31, 557–566. http://dx.doi.org/10.1055/s-0033-
1364191
Moise, K. Y., Kugler, L., & Jones, T. (2012). Contemporary manage-
ment of complicated monochorionic twins. Journal of Obstetric,
Gynecologic, & Neonatal Nursing, 43, 434–444. http://dx.doi.
org/10.1111/j.1552-6909.2012.01355.x
Nast, I., Bolten, M., Meinlschmidt, G., & Hellhammer, D. H. (2013).
How to measure prenatal stress? A systematic review of psy-
chometric instruments to assess psychosocial stress during
pregnancy. Paediatric Perinatal Epidemiology, 27, 313–322.
http://dx.doi.org/10.1111/ppe.12051
Parker, S. E., Mai, C. T., Canfield, M. A., Rickard, R., Wang, Y., Meyer,
R. E., … Correa, A. (2010). Updated national birth prevalence
estimates for selected birth defects in the United States, 2004–
2006. Birth Defects Research Part A: Clinical and Molecular
Teratology, 88(12), 1008–1016. http://dx.doi.org/10.1002/bdra.
20735
Rezaee, R., & Framarzi, M. (2014). Predictors of mental health during
pregnancy. Iranian Journal of Nursing and Midwifery Research,
19(7 Suppl. 1), 45–50.
Rofe, Y., Blittner, M., & Lewin, I. (1993). Emotional experiences during
the three trimesters of pregnancy. Journal of Clinical Psychol-
ogy, 49, 3–12. http://dx.doi.org/10.1002/1097-4679(199301)49:
1<3::AID-JCLP2270490102>3.0.CO;2-A
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896

Rosenberg, K. B., Monk, C., Glickstein, J. S., Levasseur, S. M.,
Simpson, L. L., Kleinman, C. S., & Williams, I. A. (2010). Referral
for fetal echocardiography is associated with increased
maternal anxiety. Journal of Psychosomatic Obstetics &
Gynaecology, 31, 60–69. http://dx.doi.org/10.3109/016748210
03681472
Schechtman, K. B., Gray, D. L., Baty, J. D., & Rothman, S. M. (2002).
Decision-making for termination of pregnancies with fetal
anomalies: Analysis of 53,000 pregnancies. Obstetrics and
Gynecology, 99, 216–222. http://dx.doi.org/10.1016/S0029-
7844(01)01673-8
Skari, H., Malt, U. F., Bjornland, K., Egeland, T., Haugen, G., Skreden,
M., … Emblem, R. (2006). Prenatal diagnosis of congenital
malformations and parental psychological distress—A
prospective longitudinal cohort study. Prenatal Diagnosis, 26,
1001–1009. http://dx.doi.org/10.1002/pd.1542
Spielberger, C. D., & Gorsuch, R. L. (1983). Manual for the State-Trait
Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psycholo-
gists Press.
Statham, H., Solomou, W., & Chitty, L. (2000). Prenatal diagnosis of fetal
abnormality: Psychological effects on women in low-risk pregnan-
cies. Baillire’s best practice & research. Clinical Obstetrics & Gy-
naecology,14,731–747.http://dx.doi.org/10.1053/beog.2000.0108
Titapant, V., & Chuenwattana, P. (2015). Psychological effects of fetal
diagnoses of non-lethal congenital anomalies on the experience
of pregnant women during the remainder of their pregnancy.
Journal of Obstetrics and Gynaecology Research, 41, 77–83.
http://dx.doi.org/10.1111/jog.12504
897
898
899
900
901
902
903
904
905
906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926

Maternal anxiety related to prenatal

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Similar to Maternal anxiety related to prenatal

Similar to Maternal anxiety related to prenatal (20)

Recently uploaded

Recently uploaded (20)

Maternal anxiety related to prenatal