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Predominant approaches to measuring pregnancy-related anxiety in Sub-saharan Africa: a scoping review

樱花视频 volume听24, Article听number:听2425 (2024) Cite this article

Abstract

Background

Pregnancy-related anxiety significantly impacts maternal and fetal health in low- and middle-income countries (LMICs), including those within Sub-Saharan Africa (SSA). Most studies conducted to evaluate pregnancy-related anxiety in LMICs have utilized scales developed in high-income countries, despite significant variations in pregnancy-related anxiety due to socioeconomic and cultural contexts. This review surveyed existing literature in order to identify which scales have been used to measure pregnancy-related anxiety in SSA.

Methods

A systematic search was conducted in PubMed, Health and Psychosocial Instruments, and APA PsycNet for relevant studies published in the English language up to March 22, 2023. Eligible studies focused on anxiety in pregnant populations within SSA, using validated scales or tools. Screening followed PRIMSA guidelines, with blinded review at the abstract/title level and subsequent full-text review. Data was extracted and analyzed to identify trends and characteristics of the screening tools used.

Results

From 271 articles, 37 met inclusion criteria, identifying 24 different tools used to measure anxiety in pregnant women in SSA. The most common tools were the Generalized Anxiety Disorder 7-item scale (seven uses), State-Trait Anxiety Inventory (five uses), and the Self-Reporting Questionnaire 20 (five uses). Seven tools were pregnancy-specific, with only two designed specifically for SSA: the Risk Factor Assessment (RFA), and the 4-Item Screening Tool. Studies were most frequently conducted in South Africa, followed by Tanzania, Ethiopia, Nigeria, and Ghana.

Conclusions

This scoping review illustrates that only two tools (the RFA and 4-item Screening Tool) were created to assess pregnancy-related anxiety specifically in SSA. This highlights the need for more culturally sensitive tools tailored to the specific contexts of pregnant populations in SSA.

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Background

Pregnancy-related anxiety is defined as worry associated specifically with maternal or infant outcomes, making it distinct from generalized anxiety disorder (GAD) [1]. In fact, studies have shown that most women with anxiety in pregnancy had worries not associated with GAD [1]. A concept analysis broke pregnancy-related anxiety into nine cognitive dimensions: anxiety around fetal health, loss of fetus, childbirth, mother鈥檚 wellbeing, body image, parenting and care for child, general health care, financial, and family/social support [2].

Pregnancy-related anxiety is a pervasive concern that affects pregnant individuals worldwide across income levels and geographic locations. Globally, approximately 15.2% of pregnant women meet criteria for an anxiety disorder [3]. Untreated maternal anxiety or depression may increase risk for adverse pregnancy outcomes such as gestational diabetes mellitus, fetal growth restriction, preterm birth, or fetal demise by nearly 3.5 times [4]. Moreover, recent studies have demonstrated a strong association between maternal anxiety and adverse socioemotional, cognitive, motor, and behavioral outcomes in their children. These negative developmental consequences can extend beyond infancy and have enduring effects throughout childhood and adolescence [5].

In low- and middle-income countries (LMICs), the prevalence of anxiety symptoms during pregnancy is even higher than in high-income countries, with reports suggesting that one in four women experience anxiety symptoms [4]. In LMICs, pregnancy-related anxiety represents a particularly significant burden due to the numerous challenges faced by pregnant individuals, including limited access to healthcare, poverty, and social disparities [6]. Sub-Saharan Africa (SSA) notably contains LMICs with the highest rates of maternal morbidity and mortality [7]. Risk factors for development of maternal mood disorders (poverty, food insecurity, intimate partner violence, and comorbid medical conditions) are common in many countries within SSA [8]. However, research on prevalence of pregnancy-related anxiety in SSA has been limited [8, 9].

Determining the prevalence of pregnancy-related anxiety depends on the adaptation and execution of validated scales to measure anxiety. Most of the existing research conducted in SSA settings has relied on scales and measures developed in high-income countries. However, scales developed in high-income countries may not adequately capture the unique determinants of pregnancy-related anxiety in SSA [10,11,12]. Additionally, in applying these scales, users may encounter barriers such as translation errors, administrative challenges in limited-resource settings, or overly complex and inaccessible language [10, 13]. Furthermore, the concerns of pregnant women and clinical presentation of pregnancy-related anxiety in SSA may be distinct due to cultural differences [10, 14, 15]. This highlights the need for culturally and contextually sensitive scales that are specifically validated for use in SSA populations. Site-specific validated scales are needed to quantify the overall burden of pregnancy-related anxiety, evaluate individual patients in clinical environments, and accurately assess the efficacy and impact of mental health interventions [16].

To address these critical gaps, we undertook a scoping review of validated screening tools for detecting pregnancy-related anxiety in SSA, with a focus on identifying scales validated within SSA contexts. Throughout this review, we aimed to (1) describe the use of pregnancy-related anxiety scales evaluated in the literature by type of scale and study setting, and (2) summarize characteristics of the scales, including length and question type, that may impact the practicality of administration in low-resource settings.

Methods

This scoping review was conducted following the recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [17] and adhered to the methodological framework first outlined by Arksey & O鈥橫alley [18].

The primary aim of this scoping review was to identify and determine the current screening tools utilized to assess pregnancy-related anxiety in SSA. The scope of this project was intentionally limited and not intended to serve as a comprehensive synthesis or systematic review of all relevant literature on pregnancy-related anxiety in SSA. As such, it provides an overview of the tools and methodologies applied in existing studies rather than an exhaustive analysis.

Information sources, search strategy, and eligibility criteria

A comprehensive search strategy was developed by the research team, which consisted of an obstetrician, research assistants, medical students, and an experienced health sciences librarian. The databases PubMed, Health and Psychosocial Instruments (HaPI), and APA PsycNet were searched systematically for relevant studies in the English language that assessed pregnancy-related anxiety in SSA using validated scales. All searches were conducted on March 22, 2023 and included any relevant studies published up to that date. The search terms encompassed concepts related to pregnancy, anxiety, Sub-Saharan Africa, and tool evaluation (Table听1). The search strategy adhered to the PRISMA guidelines, with Fig.听1 outlining the search refinement process.

Table 1 Search strategy terms
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Fig. 1
figure 1

PRISMA flow chart of study selection

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The initial database search identified 281 records, from which 12 duplicate articles were removed, yielding 269 unique records. These were exported to Rayyan, a web-based tool designed for reviews. An additional two articles were identified through reference list reviews, bringing the total to 271 articles for screening. Abstracts and titles were reviewed blindly by three independent researchers (SF, TS, IK) using inclusion criteria and exclusion criteria, as detailed below. Blinding limited bias by preventing reviewers from seeing each other鈥檚 decisions until all articles had been independently reviewed. Articles were included only if all three readers agreed on inclusion, and discrepancies were resolved via consensus discussions.

From the 271 article abstracts screened for inclusion, 59 met the initial criteria and were subjected to full-text review. Of these, 37 articles were deemed relevant for data extraction, with exclusions made for reasons such as duplicate data, focus on postpartum cohorts, or research conducted outside of SSA, as detailed in the PRISMA diagram (Fig.听1).

Eligible studies were required to meet the following criteria: (1) focus on anxiety screening, (2) examination of anxiety specifically among pregnant women, (3) conduct of research in Sub-Saharan Africa, and (4) use of a specific, validated scale or tool for evaluating pregnancy-related anxiety. Studies with a primary focus on other psychological conditions (e.g., depression, psychosis) were included only if they provided data on pregnancy-related anxiety measures.

During the search process, it was noted that many scales utilized were not specific to pregnancy-related anxiety but were originally developed for GAD. Despite the distinct nature and presentation of pregnancy-related anxiety [1], these generalized scales were included to reflect historical and current practices in the assessment of anxiety during pregnancy. Additionally, studies evaluating peripartum 鈥渃ommon mental disorders,鈥� as previously defined by the World Health Organization [19], were included in the review.

Exclusion criteria included (1) studies that utilized qualitative methods, such as narrative descriptions, (2) studies that utilized focus groups, (3) studies that assessed pregnancy-related anxiety in retrospect, and听(4) unpublished studies or studies pending publication.

Data extraction

Data was extracted and reviewed by three authors (SF, IK, TS). Each full text article was examined for the country of study implementation, the number of participants, participant age range, the screening tool(s) used, and the outcome examined (e.g., common mental disorder vs. anxiety) (Table听2). In cases where multiple screening tools were used to evaluate different outcomes, only data pertaining to anxiety measurement were extracted; scales that exclusively measured another mental health disorder without components of anxiety (e.g., depression, psychosis) were excluded. An exception was made for three studies that utilized the Edinburgh Postnatal Depression Scale (EPDS) to measure anxiety symptoms in pregnant women [20,21,22]. No additional studies were identified for inclusion upon further review of references.

Table 2 Studies included in review on pregnancy-related anxiety in Sub-saharan Africa
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The final stage of data extraction was performed on each full-length pregnancy anxiety screening tool, to examine the characteristics of each tool. Reviewers obtained data on the pregnancy-specificity of each tool, as well as the number of questions, types of questions, and number of answer options (Table听3).

Table 3 Screening tools assessing pregnancy-related anxiety in Sub-saharan Africa
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Data synthesis

Extracted data were analyzed to identify trends in the use of screening tools across SSA, including country-specific usage patterns. First, data for each pregnancy-related anxiety screening tool was analyzed. Geographic data was compiled, examining the different countries each scale was used in and the number of instances of use in each country. This data was then synthesized along with the data extracted regarding scale characteristics (pregnancy specificity, number of questions, type of scale, number of question options), providing a comprehensive overview of the usage and characteristics of each screening tool (Table听3).

Data was then analyzed by country, examining which scales were used in each country, and in how many instances they were used (Table听4).

Table 4 Scales used to evaluate pregnancy-related anxiety by country
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Results

Study selection

The study selection is outlined in the PRISMA diagram (Fig.听1). All the included studies assessed pregnancy-related anxiety, with individual studies doing so at different points across all trimesters. Various methods were used to quantify levels of anxiety, with some studies having cut-off scores and others providing ranges to estimate anxiety.

Study characteristics

Thirty-five full-text articles contained studies that used a scale to evaluate mental health in pregnant women [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] (Table听2). The specific outcomes evaluated in the studies varied slightly, but all studies were focused on evaluating forms of anxiety during pregnancy. Of the 35 studies, the most common outcome examined was anxiety (13 studies), followed by common mental disorders (seven studies), anxiety and depression (four studies), psychological distress (three studies), and childbirth fear (two studies) (Table听2).

Synthesis of results

Research on pregnancy-related anxiety in SSA was conducted in 10 different countries (Table听4; Fig.听2). The most frequent locations for the studies were South Africa (11 studies); Tanzania, Ethiopia, and Nigeria (five studies each); and Ghana (four studies) (Table听4). Each use of a scale in each study was counted as one data point and extrapolated into a heat map (Fig.听2). If a study used multiple scales, it was counted as multiple points on the heat map (i.e., a study that used the Generalized Anxiety Disorder 7-item scale (GAD-7) and the EPDS would count for two points on the heat map).

Fig. 2
figure 2

Frequency of studies on pregnancy-related anxiety by country

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The most-used tools to evaluate pregnancy-related mental health in SSA were the GAD-7 (seven uses), State-Trait Anxiety Inventory (STAI; five uses), and Self-Reporting Questionnaire 20 (SRQ-20; five uses) (Table听3).

The 35 studies included in this review yielded 24 different tools to evaluate pregnancy-related anxiety in SSA. Nineteen of the 24 tools (79%) used Likert scales for their question type, four (17%) used yes/no questions, and one (4%) used ranking on a number line. Importantly, only seven of the 24 tools were developed to be used specifically in pregnant populations. Only two tools were developed specifically for use in SSA鈥攖he 4-item Screening Tool and the Risk Factor Assessment (RFA). These were both developed in South Africa, with the intention of being applied there [16, 17]. Three other tools have been adapted for use in SSA: the Pregnancy-related Anxiety Scale (PrAS), the Pregnancy-Related Anxiety Questionnaire (PRAQ), and the Tilburg Pregnancy Distress Scale (TPDS) [9]. Studies included in this review were published between 1994 and 2022, with 74% (26/35) published in or after 2015, suggesting an increasing focus on pregnancy-related anxiety in SSA in recent years.

Discussion

Few systematic reviews have described the screening tools used to evaluate pregnancy-related anxiety, and to our knowledge this review is the first to examine the use of these tools specifically in SSA. Three key themes emerged from this review: (1) the use of pregnancy-specific versus general anxiety scales; (2) the cultural relevance of screening tools specifically designed for LMICs鈥攑articularly SSA; and (3) the challenges of implementing these tools in these regions.

Regarding themes 1 and 2, of the 24 scales evaluated, only seven were developed specifically for pregnancy-related anxiety. Of these, only five were designed with LMIC contexts in mind: the RFA, the 4-Item Screening Tool, the PRAQ, the PrAS, and the TPDS [12, 21, 22]. Despite the relevance of these tools, the most frequently used tools in SSA were general anxiety scales, such as the GAD-7, the STAI, and the SRQ-20鈥攏one of which are pregnancy-specific. The frequent use of these general scales raises questions about their appropriateness in assessing pregnancy-related anxiety due to the significant clinical distinctions between pregnancy-related and general anxiety. Pregnancy introduces a unique set of stressors鈥攆inancial, social, and health-related鈥攖hat are not typically assessed by general anxiety scales [2, 12]. The GAD-7 has been validated for use in several LMICs, such as Zimbabwe and Ghana, but its lack of pregnancy-specific focus may limit its efficacy in evaluating pregnancy-related anxiety [55]. Nonetheless, a recent study in Peru did show that the GAD-7 may have promise in evaluating pregnancy-related anxiety; however, this requires further investigation [56]. The SRQ-20, though developed by the World Health Organization for use in LMICs, similarly lacks a pregnancy-specific focus [57]. The STAI, despite its widespread use, has limited validation in LMICs, with Malaysia being the sole LMIC in which it is validated [58, 59]. These findings underscore the importance of expanding the use and validation of pregnancy-specific scales in LMICs to ensure accurate assessment of pregnancy-related anxiety.

For theme 3, many obstacles remain when applying pregnancy-related anxiety screening tools to SSA contexts, as 19 of the 24 tools evaluated were developed for use in high-income countries. Cultural and economic stressors can be a source of anxiety for pregnant women, and scales developed in high-income countries may not adequately capture these factors and how they relate to pregnancy [10]. The practical challenges of implementing these tools鈥攕uch as language barriers, difficulties in translating scales, time and resources needed to validate a screening tool in a new population [60], and the complexity of Likert scales鈥攑ose significant obstacles to their effective use in resource-limited settings.

Strengths and limitations

This study was limited by three main factors. First, the exclusion of non-English language studies may have led to the omission of relevant research, particularly from French- and Portuguese-speaking countries in SSA. This limitation could introduce a bias in our findings, as it may not fully represent the diversity of experiences and practices across SSA. It also prevented the use of databases that may have been relevant to our search such as Africa Wide, limiting the generalizability of our findings. Second, while we included studies that utilized scales validated for use in LMICs, these validations were often limited to specific countries or regions, which may limit their generalizability to other LMIC contexts. Given the diverse cultural and socioeconomic environments within SSA, it is crucial to refrain from characterizing SSA as a monolith, and we must consider that a tool validated in one country or population may not be appropriate for another within SSA. Additionally, external factors such as political shifts or climate change may necessitate the reappraisal and revalidation of these scales over time. Third, our review included a number of studies that utilized general anxiety scales in their aim to evaluate pregnancy-related anxiety. These scales typically included a limited number of questions related to worries of pregnancy and may not fully capture the unique symptomatology and trajectory of anxiety during pregnancy [61].

Conclusions

This scoping review sheds light on the current state of tools used to evaluate pregnancy-related anxiety in SSA and underscores the critical need for contextually appropriate tools that account for the unique stressors faced by pregnant women in these settings. Future research should prioritize tool development and validation, ensuring their practicality and ease of use in resource-constrained environments. This includes adapting tools to account for language barriers, simplifying scales for varying literacy, and ensuring compatibility with existing healthcare systems. Addressing these gaps may allow for future studies that track the course of pregnancy-related anxiety in SSA longitudinally, providing evidence to inform targeted interventions and policy decisions, and ultimately improving the mental health outcomes of pregnant women in these regions.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

LMIC:

Low- or middle-income country

SSA:

Sub-Saharan Africa

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

EPDS:

Edinburgh Postnatal Depression Scale

GAD-7:

Generalized Anxiety Disorder 7

STAI:

State-Trait Anxiety Inventory

SRQ-20:

Self-Reporting Questionnaire 20

PRAQ:

Pregnancy Related Anxiety Questionnaire

PRAS-r:

Pregnancy-related Anxiety Scale-revised

W-DEQ-A:

Wijma Delivery Expectancy/Experience Questionnaire

RFA:

Risk Factor Assessment

TPDS:

Tilburg Pregnancy Distress Scale

SAS:

Zung Self-rating Anxiety Scale

HADS:

Hospital Anxiety and Depression Scale

WHODAS 2.0:

World Health Organization Disability Assessment Schedule 2.0

K10:

Kessler Psychological Distress Scale

GAD-2:

Generalized Anxiety Disorder 2

BSI-18:

Brief Symptoms Index

BAI:

Beck Anxiety Inventory

PSS:

Perceived Stress Scale

DASS-21:

Depression Anxiety Stress Scale-21

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Authors and Affiliations

  1. University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 48109, USA

    Sophia Dane Fraga,听Ibrahim Nawaz Khan听&听Tanvi A. Sharma

  2. Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA

    Emma R. Lawrence

Authors
  1. Sophia Dane Fraga

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  2. Ibrahim Nawaz Khan

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  3. Tanvi A. Sharma

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  4. Emma R. Lawrence

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Contributions

SF contributed substantially to the data acquisition in this manuscript, simultaneously authoring the methods section to document all steps towards data acquisition. SF synthesized all data into the results and discussion components.听IK authored the introduction component of this scoping review and served as a blind reviewer in the abstract review phase of data acquisition. IK served as primary editor for the final manuscript.听TS served as a blind reviewer in the abstract review phase of data acquisition. TS assisted with data extraction from the identified pregnancy-related anxiety scales, contributing significantly to the results and discussion section. ERL contributed substantially to the conception and design of the work, drawing on her past work in Ghana to determine a research direction for this scoping review. SF, IK, TS, and ERL critically reviewed the manuscript, approved the final version to be published, and agree to be accountable for all aspects of the work ensuring that questions related to integrity are appropriately investigated.

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Correspondence to Sophia Dane Fraga.

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Fraga, S.D., Khan, I.N., Sharma, T.A. et al. Predominant approaches to measuring pregnancy-related anxiety in Sub-saharan Africa: a scoping review. 樱花视频 24, 2425 (2024). https://doi.org/10.1186/s12889-024-19935-3

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  • DOI: https://doi.org/10.1186/s12889-024-19935-3

Keywords

樱花视频

ISSN: 1471-2458

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