Introduction
The perinatal period, from conception to 2 years postpartum, represents a time of normative transition that can be experienced as stressful or cause anxiety for some women. Stress and anxiety are highly related, yet distinct concepts (Glover Reference Glover2011). Stress is defined as occurring when external demands are perceived to exceed a person’s capacity to cope with those demands (Lazarus Reference Lazarus1966; Lazarus and Folkman Reference Lazarus and Folkman1984). Anxiety is a state of tension or apprehension resulting from an uncertain or unpredictable prospective internal or external threat (American Psychiatric Association, 2013; Knight and Depue Reference Knight and Depue2019). Up to 84%, and approximately 15–25% of women experience perinatal stress (Woods et al., Reference Woods, Melville, Guo, Fan and Gavin2010) and anxiety (Dennis et al., Reference Dennis, Falah-Hassani and Shiri2017), respectively. Perinatal stress and/or anxiety are associated with a range of adverse obstetric, child, and maternal outcomes. These include increased risk of preterm birth (Lobel et al., Reference Lobel, Cannella, Graham, DeVincent, Schneider and Meyer2008), low birth weight (Bussières et al., Reference Bussières, Tarabulsy, Pearson, Tessier, Forest and Giguère2015), small for gestational age infants, reduced foetal growth (Khashan et al., Reference Khashan, Everard, McCowan, Dekker, Moss-Morris, Baker, Poston, Walker and Kenny2014; Lewis et al., Reference Lewis, Austin and Galbally2016), along with child neurodevelopmental (Adamson et al., Reference Adamson, Letourneau and Lebel2018), socioemotional (Madigan et al., Reference Madigan, Oatley, Racine, Fearon, Schumacher, Akbari, Cooke and Tarabulsy2018), and physical health outcomes (Zijlmans et al., Reference Zijlmans, Riksen-Walraven and De Weerth2015). Perinatal stress and anxiety can also adversely impact maternal-child attachment (Göbel et al., Reference Göbel, Stuhrmann, Harder, Schulte-Markwort and Mudra2018) and contribute to maternal depression (Hutchens and Kearney Reference Hutchens and Kearney2020; Norhayati et al., Reference Norhayati, Nik Hazlina, Asrenee and Wan Emilin2015) and perinatal health behaviours (Bailey and Sokol Reference Bailey and Sokol2011; Davenport et al., Reference Davenport, Ruchat, Poitras, Jaramillo Garcia, Gray and Barrowman2018; Fallon et al., Reference Fallon, Bennett and Harrold2016; Lindsay et al., Reference Lindsay, Buss, Wadhwa and Entringer2017; Riaz et al., Reference Riaz, Lewis, Naughton and Ussher2018).
Stress and anxiety during the perinatal period can result from sociodemographic, psychological, physiological, and social risk factors (Bayrampour et al., Reference Bayrampour, Vinturache, Hetherington, Lorenzetti and Tough2018; Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016). Such factors include experiencing adverse or stressful life events (e.g. intimate partner violence, bereavement), current or past medical complications during pregnancy (Bayrampour et al., Reference Bayrampour, Vinturache, Hetherington, Lorenzetti and Tough2018; Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016), having a history of mental health issues, and inadequate social support (Bayrampour et al., Reference Bayrampour, Vinturache, Hetherington, Lorenzetti and Tough2018; Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016; Huschke et al., Reference Huschke, Murphy-Tighe and Barry2020). Poor healthcare experiences, unrealistic social norms and expectations, health-related concerns (McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021), maternal age, parity, and income, as well as infant health complications (Goodman et al., Reference Goodman, Watson and Stubbs2016; McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021; Saur and Dos Santos Reference Saur and Dos Santos2021; Suwalska et al., Reference Suwalska, Napierała, Bogdański, Łojko, Wszołek, Suchowiak and Suwalska2021), also influence perinatal stress and anxiety. In addition, the transitional nature of the perinatal period, with associated changes in roles and responsibilities, can lead to stress and anxiety (Huizink et al., Reference Huizink, Menting, De Moor, Verhage, Kunseler, Schuengel and Oosterman2017). Importantly, sources, experiences, and approaches to coping with stress and anxiety can vary across the perinatal period (Rallis et al., Reference Rallis, Skouteris, McCabe and Milgrom2014).
Several approaches have been developed and/or used to reduce or prevent perinatal stress and anxiety. These include Cognitive Behavioural Therapy, interpersonal therapy, and psycho-educational and mindfulness-based interventions. However, the effects of these interventions, across the perinatal period, are inconsistent (Matvienko-Sikar et al., Reference Matvienko-Sikar, Redsell and Flannery2023, Reference Matvienko-Sikar, Flannery, Redsell, Hayes, Kearney and Huizink2021). Observed inconsistencies may arise due to interventions typically being targeted at either pregnancy or the postnatal period (Matvienko-Sikar et al., Reference Matvienko-Sikar, Redsell and Flannery2023), which fails to consider the transitional nature of the perinatal period. Further, in the intervention literature, the predominant focus is on interventions developed to target other mental health issues such as depression, rather than interventions specifically focusing on stress and anxiety (Matvienko-Sikar et al., Reference Matvienko-Sikar, Redsell and Flannery2023). Similarly, interventions are typically aimed at vulnerable or ‘at-risk’ populations (Matvienko-Sikar et al., Reference Matvienko-Sikar, Redsell and Flannery2023), which fails to address perinatal stress and anxiety at the population level. In addition, the development and delivery of interventions for perinatal stress and anxiety do not always consider the experiences, needs, and preferences of the women they intend to support. Interventions that are appropriate and acceptable to women are more likely to be effective (Manolova et al., Reference Manolova, Waqas, Chowdhary, Salisbury and Dua2023).
This research aims to investigate perceived sources and experiences of stress and anxiety across the first 1000 days in an Irish population to inform approaches to perinatal stress and anxiety reduction. The study also examines women’s attitudes and experiences of available supports and preferences for alternative/new supports to reduce maternal stress and anxiety.
Methods
Design
An online mixed-methods cross-sectional survey was conducted, including closed and open-ended questions.
Participants
Participants were over 18 years old, currently pregnant, or self-identify as the mother of a child ≤ 2 years and have received/are receiving their antenatal and/or perinatal care in the Republic of Ireland. Participants were not excluded based on ethnicity or any sociodemographic factors.
Procedure
A convenience sampling strategy was used, with recruitment from 20 March to 31 May 2023. Online recruitment was conducted via social media (e.g. Facebook, Instagram, Twitter), and pregnancy and parenting-related forums (e.g. What to Expect). Participants were also recruited via posters displayed in medical centres and family resource centres in the south and west of Ireland.
Materials/Survey
Participants completed different versions of the survey depending on whether they were currently pregnant or had a child ≤2 years old (herein referred to as ‘mothers’). Pregnant participants who also had a child ≤2 years were instructed to respond in relation to their current pregnancy. Both surveys included closed and open-ended questions. See Supplementary File 1 for full surveys.
Sociodemographic data. All participants provided information on their age, nationality, relationship status, employment status, education level, cigarette smoking, alcohol intake, type of antenatal care, satisfaction with antenatal care, whether their pregnancy was planned, number of previous pregnancies, number of other children, and experiences of previous and current health difficulties. In addition, pregnant participants were asked the current gestational week of their pregnancy. Mothers were asked the age of their youngest child, about their child’s health, birth complications, and how they feed their child.
Perceived stress scale (PSS). Perceived levels of psychological stress were assessed on the 10-item PSS (Cohen et al., Reference Cohen, Kamarck and Mermelstein1983) in mothers only. This scale measures the degree to which participants’ experience their lives as unpredictable, uncontrollable, and overloaded in the last month. Items are measured on a 5-point Likert scale from ‘never’ to ‘very often’, with possible scores ranging from 0 to 40. The reliability of the PSS in the current study was α = 0.88.
Pregnancy distress questionnaire (PDQ). Pregnancy-specific stress was assessed in pregnant participants only using the PDQ (Yali and Lobel Reference Yali and Lobel1999). This 12-item scale measures specific worries and concerns during pregnancy regarding physical symptoms, medical problems, relationships, parenting, labour and delivery, and the health of the baby. Participants respond to statements using a 5-point Likert scale ranging from ‘not at all’ to ‘extremely’. In the current study, the PDQ had an internal consistency coefficient of α = 0.86.
Perinatal anxiety screening scale (PASS). The PASS is a 31-item measure of self-reported perinatal anxiety (Somerville et al., Reference Somerville, Dedman, Hagan, Oxnam, Wettinger, Byrne, Coo, Doherty and Page2014), using a 4-point Likert scale from ‘not at all’ to ‘all the time’. Scores range from 0 to 93, with scores above 26 suggesting elevated levels of anxiety (Somerville et al., Reference Somerville, Dedman, Hagan, Oxnam, Wettinger, Byrne, Coo, Doherty and Page2014). In the current study, the reliability coefficient of the PASS was α = 0.96.
Multidimensional scale of perceived social support (MSPSS). Participants’ perceived levels of social support were measured using the 12-item MSPSS (Zimet et al., Reference Zimet, Dahlem, Zimet and Farley1988). This scale measures perceived support from family, friends, and significant others on a 7-point scale from ‘very strongly disagree’ to ‘very strongly agree’. In the current study, the reliability of the overall scale was α = 0.95, the reliability of the significant other subscale was α = 0.96, the friends subscale was α = 0.96, and the family subscale was α = 0.94.
Brief resilience scale (BRS). The BRS assesses ability to rebound or recover from stress (Smith et al., Reference Smith, Dalen, Wiggins, Tooley, Christopher and Bernard2008). It is comprised of 6-items, measured on a 5-point Likert scale from ‘strongly disagree’ to ‘strongly agree’. Higher scores represent greater resilience in dealing with adversity. In the current study, the reliability of the BRS was α = 0.88.
Open-ended questions. Open-ended questions (eight for pregnant participants, nine for mothers) were developed by a multidisciplinary team based on existing evidence (McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021). Questions explored participants’ experiences of stress and anxiety either during pregnancy or postpartum, as well as their experiences and preferences for existing and alternative supports to minimise perinatal stress and anxiety. See Supplementary File 1 for full questions.
Ethics
Ethical approval for the study was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Participants were provided with study information prior to completing the questionnaire, and informed consent was obtained from all participants prior to commencement of the online survey.
Analysis
Quantitative analysis. Descriptive statistics were calculated for sociodemographic factors, stress, anxiety, social support, and resilience. Non-parametric inferential statistics were calculated as data were non-normally distributed. Chi-squared tests were conducted to examine differences between pregnant women and mothers for categorical sociodemographic factors. Mann–Whitney U tests were conducted to examine differences in continuous sociodemographic factors, social support, resilience, and anxiety. Spearman’s rank order correlations (for continuous variables) and point biserial correlations (for relationships between dichotomous categorical variables and continuous variables) were used to examine the role of sociodemographic variables, social support, and resilience in women’s self-reported stress and anxiety. Bonferroni corrections were applied with a more conservative significance value of p < 0.0025, to account for multiple inferential tests.
Qualitative analysis. Open-ended responses were analysed with reflexive thematic analysis (Braun and Clarke Reference Braun and Clarke2021) supported by NVivo-20 software. Reflexive thematic analysis involves six phases: familiarisation with the data; initial open-coding; producing initial themes; reviewing themes; refining, defining, and naming themes; and writing up the analysis. Themes were generated, discussed, and reviewed by the full team throughout the process. Reflexive thematic analysis allows for consideration of researchers’ subjective interpretations. It acknowledges the role of researchers’ previous experiences, potential biases, and social positions in analyses. In this study, EL and KMS are psychologists, with experience in child health services, and conducting research on maternal and child health, respectively. SR is also a health psychologist and a public health nurse (health visitor). CH is a registered general and children’s nurse who currently lectures in nursing. KMS and CH are mothers of young children; SR is the mother of a young adult who was born very preterm.
Results
Seven hundred women completed the survey: 214 (30.57%) pregnant women and 486 (69.43%) mothers. Participants were aged between 18 and 46 years (Median = 35, IQR = 5); 96.29% (n = 674) identified as Irish nationals. The majority of participants were married (74.32%), in paid employment (91.57%), and had completed education to a degree level or above (88.64%). Mothers were significantly more likely than pregnant women to have a higher number of previous pregnancies, more children, and have experienced a high-risk pregnancy or pregnancy complications in their most recent pregnancy. Pregnant women were significantly more likely to experience physical or psychological difficulties in previous pregnancies and reported significantly higher prenatal alcohol consumption, overall social support, and social support from significant others than mothers. See Table 1 for participant characteristics (see Supplementary File 2 for extended participant details).
Table 1. Participant characteristics
- no relevant data.
^ chi-square test carried out comparing Irish and not Irish due to small numbers in other groups.
^^ chi-square test carried out comparing any alcohol and no alcohol due to small numbers in other groups.
* European: British; Croatian; Danish; Dutch; French; German; Italian; Spanish.
North American: USA.
Other: Brazilian; Chilean; South African; Venezuelan.
** Below degree level: secondary school; technical/vocational qualification; Non-degree qualification.
*** 6 or more standard drinks: 6–10 standard drinks; 11 or more standard drinks.
Pregnant women’s median perceived stress score was 16 (range 0–42); the mother’s median perceived stress score was 20 (range 1–40). Pregnant women reported non-significantly lower anxiety than mothers (p = 0.021). See Table 2 for full mental health outcome characteristics.
Table 2. Mental health outcome characteristics
Due to low levels of variance in participant nationality, relationship status, employment, education, smoking and alcohol behaviours, and satisfaction with antenatal care, these variables were excluded from analyses. In correlational analyses, lower levels of perceived social support (overall and for each subscale) and resilience were significantly associated with higher levels of anxiety and stress in pregnant women and mothers (all p < 0.001). Previous diagnosis of a mental health disorder/issue was significantly associated with higher anxiety in pregnant women, mothers, and the overall sample (all p < 0.001), and higher stress for mothers only (p < 0.001). Experiencing a high-risk pregnancy or pregnancy complications in their most recent pregnancy was significantly associated with higher anxiety for mothers (p = 0.006), and the full sample (p = 0.007) but not for pregnant women (p = 0.91). Experiencing a high-risk pregnancy or pregnancy complications was not associated with stress for either pregnant women (p = 0.83) or mothers (p = 0.03). ‘Excellent’ child health at birth only was associated with lower maternal anxiety (p = 0.004). ‘Excellent’ child health at both birth and now was associated with lower maternal stress (both p < 0.001). No other demographic factors were significantly correlated with stress or anxiety. See Supplementary File 3 for correlation tables.
Qualitative findings
Five themes were developed. Four themes relate to women’s experiences of causes, impacts, and ways of coping with stress and anxiety across the perinatal period: (1) perceived responsibilities; (2) self-care; (3) care for maternal health and well-being; (4) and social support. The fifth theme, access to support and information, outlines women’s perception of the role of healthcare professionals in helping them find support and information in an accessible way. Example quotes for all themes are presented in Table 3. Unless otherwise stated, all findings relate to the experiences of women across the perinatal period.
Table 3. Themes and exemplar quotes
Perceived responsibilities
Many women identified that balancing the different responsibilities in their lives was a source of stress and anxiety. Perceived responsibilities included children’s well-being, women’s role as (an expectant) parent, and general life worries. The health and well-being of their children were a constant source of worry throughout the perinatal period. Women’s worries included fear of miscarriage, concerns about the health of the baby when they are born, and/or that ‘bad things’ could happen to their child in the future. Mothers also expressed anxiety around their baby’s eating, sleeping, and meeting their developmental milestones. Worrying about their baby having a developmental delay, disability, or medical issues was an additional source of anxiety for some mothers.
Many women also reported stress and anxiety due to perceived responsibilities associated with pregnancy and parenthood. Mothers described the pressure of ‘getting everything right’ (Mother; ID 684) regarding their child’s well-being, now and in the future. The societal expectations associated with ‘being a good mother’ (Mother; ID 19) were a notable cause of stress, particularly if women felt they were failing to live up to these expectations. Some women described feeling pressure to breastfeed as they felt it was best for their baby, but the lack of support available for breastfeeding mothers caused additional stress. Mothers highlighted their own anxiety around returning to work and additional stress around the impact this would have on their child(ren).
Women also expressed feeling stress and anxiety related to general life issues including daily chores, work-related issues, accessing childcare, broader familial caring responsibilities, housing, and financial worries. Some women also mentioned dealing with other stressors during the perinatal period including bereavement, which significantly impacted their experiences.
Self-care
Engaging in self-care behaviours that involved taking time out for themselves, such as exercise, relaxation techniques, and holistic therapies, was important to many women. Making time for hobbies, interests, and entertainment was an important aspect of self-care. Women reported engaging in different types of exercise, including going out for walks, both by themselves and with their babies. Walking gave women an opportunity to get outside in nature and fresh air, which was important for managing stress and anxiety. Other forms of exercise such as yoga, swimming, Pilates, and going to the gym were also mentioned as helpful. Some women expressed how exercise had always been important to them and that retaining this during pregnancy and following the birth of their child was beneficial. The longer-term benefits of staying ‘fit and active’ (Pregnant; ID 34) during pregnancy and after birth were also mentioned. Holistic therapies such as breathing exercises, meditation, mindfulness, and hypnobirthing were also reported as strategies to relieve stress and anxiety.
The importance of sleep was noted. Being able to get a good night’s sleep helped women manage feelings of stress and anxiety, while sleep difficulties added to negative feelings. Women also noted, in a cyclical relationship, that feeling stressed or anxious had a negative impact on their sleep, in turn causing additional tiredness during the day. Similarly, not being able to engage in self-care strategies, including having a lack of time to themselves, was mentioned as both a cause and consequence of their anxiety and stress. It also impacted women’s desire and perceived ability to engage in self-care activities, which in turn led to further negative feelings.
Care for maternal health and well-being
Most women reported that stress and anxiety negatively impacted their health and emotional well-being. Anxiety and stress led to worry, overthinking, rumination, and feeling overwhelmed, like ‘my thoughts are on overdrive’ (Mother; ID 385), and like everything is ‘constantly building up’ (Mother; ID 165). Lack of concentration and focus and experiencing feelings of panic were also consequences of stress and anxiety.
Some women expressed that their own physical health concerns were a significant cause of stress and anxiety. These included medical issues resulting from pregnancy/childbirth (e.g. caesarean section) and health issues unrelated to pregnancy (e.g. pre-existing illnesses and COVID-19). Women were also anxious that their health issues would impact their ability to care for their children. Pregnant women expressed concerns about childbirth, including uncertainty and fear that something may go wrong, or that their wishes would not be respected during labour. This was particularly noted by women who had experienced previous difficulties during childbirth.
Some women reported engaging with formal healthcare supports such as Perinatal Mental Health Teams in local hospitals or other psychological supports including counselling and psychotherapy. Women reported that, when available, birth reflection services were helpful. Women also reported seeking healthcare supports from professionals including general practitioners, public health nurses, midwives, lactation consultants, doulas, and holistic practitioners. Many mothers reported differences in their experiences of health support services during their pregnancy compared with after their baby was born. Mothers felt that they received good mental and physical healthcare support during pregnancy but that this decreased after birth, despite needing more ongoing support in the postnatal period.
Social support
Good social support made women feel less stressed and anxious across the perinatal period. Social support included support from friends, family, partner, organised maternity/new mother groups, and the online community. However, many women felt they received less social support postpartum than during pregnancy, despite feeling they needed more support during this time to alleviate loneliness, isolation, stress, and anxiety.
Talking with women who were also pregnant or had young children, was described as very important, as these individuals had similar experiences and could share their stories. Women commented on the importance of ‘mum and baby classes’ for social support after birth and expressed a desire for additional resources in this area. These groups encouraged women to get out of the house and meet with other mothers with shared experiences. Women expressed how more openness and normalising the feelings and experiences associated with the realities of parenthood were important for dealing with stress and anxiety. Social media and pregnancy/parenting forums also provided women with reassurance and a sense of community.
Many women also outlined the importance of both emotional and practical support from their partner, though this was reported less frequently by participants in this study. Furthermore, a lack of support from partners was a cause of stress and anxiety for women. Women described becoming irritated, frustrated, and resentful when they felt unsupported by a partner who did not seem to understand their feelings; or was perceived as not taking on the same amount of responsibility.
Stress and anxiety also impacted women’s wider social interactions and relationships. Women became disengaged, withdrew from social interactions, and did not want to be around people, including friends and family. Anxious feelings often made it harder for women to go out or in some cases stopped them from leaving their homes at all.
Access to support and information
Many women voiced a strong need for greater information, resources, and support for their physical and mental health during the perinatal period, specifically ’support as a person in my own right’ (Mother; ID 694). This was particularly noted in the postpartum period when women felt that healthcare focused more on the health of the baby than their own needs. As a result, women felt abandoned and ‘like a baby-making machine not a person’ (Mother; ID 172). Women reported wanting increased postnatal follow-up contact and support from healthcare professionals, and services to address mental health concerns. Information about when to seek additional support and when they needed to engage with healthcare professionals was also important to women.
Women also expressed a need to know more about available mental health supports during the perinatal period; including where to access supports, resources, and information. Although some women had engaged with the Irish Perinatal Mental Health Services, some felt there should be more information and awareness about this service. Other women attended private therapy or counselling because they had been unable to access psychological support through the public system or did not know if it was available. Women reported that they would like to receive information, resources, and supports to help with stress and anxiety in a flexible manner. Flexibility was seen as ensuring ‘women can have multiple ways of accessing [supports]’ (Pregnant; ID 644) and they could access support in the most suitable way for their needs at that time.
Discussion
This study examined women’s perceived sources and experiences of perinatal stress and anxiety and their experiences and needs for perinatal mental health supports. Several factors were found to contribute to perinatal stress and/or anxiety, including low social support, low resilience, experiencing previous maternal mental health issues, experiencing a high-risk pregnancy, and poorer perceived child health. Qualitative findings identified perceived responsibilities, concerns about maternal health and well-being, self-care, social support, and access to support and information to be associated with perinatal stress and/or anxiety.
Building on existing literature (Bayrampour et al., Reference Bayrampour, Vinturache, Hetherington, Lorenzetti and Tough2018; Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016; Huschke et al., Reference Huschke, Murphy-Tighe and Barry2020; McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021), this study provides evidence for the importance of social support in women’s experiences of perinatal stress and/or anxiety. Our finding that mothers reported significantly lower levels of perceived social support (specifically from significant others) than pregnant women was supported by qualitative findings that mothers felt they received less support in the postnatal period. This highlights an important difference in current and potential future support provision to women across the perinatal period, with a need for increased social support provision postpartum. In our study, women did not express a desire for greater partner support, though this has a significant influence on perinatal stress and/or anxiety (Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016; Huschke et al., Reference Huschke, Murphy-Tighe and Barry2020; McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021). This may be because reported social support levels were high overall. However, women in this study expressed experiences of greater support from other women who had current or previous similar experiences of pregnancy and parenting, including sisters, mothers, and pregnancy/parenting groups. Women also expressed a desire for greater availability and access to such support groups to help manage stress and/or anxiety. Engaging with these social supports to manage feelings of stress and/or anxiety is something women are already doing, and find helpful, across the perinatal period. It is therefore important to build on these positive relationships and foster these supports in the future to reduce maternal stress and/or anxiety.
Access to support groups and supportive others was often discussed in relation to gaining information, advice, and experiences about pregnancy and motherhood. Such information and support can alleviate concerns women have about their own and their baby’s health and well-being. Unsurprisingly then, and in line with previous research (Ayers et al., Reference Ayers, Crawley, Webb, Button and Thornton2019; McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021), when an infant’s health was not reported as ‘excellent’, and when women had concerns about their babies’ health, this led to increased stress and/or anxiety. It is important to note that in this study, there was a discrepancy between how women rated their child’s health (typically as very healthy) and the concerns they expressed in open-ended responses about their child’s health. Such discrepancies speak to women’s feelings of uncertainty about child health outcomes that are outside their control (Harrison et al., Reference Harrison, Moore and Lazard2020; Jones et al., Reference Jones, Harrison, Moulds and Lazard2022). Similarly, previous experiences of challenges during pregnancy, birth, and postpartum, in addition to perceptions of societal expectations about pregnancy and around motherhood, contributed to perinatal stress and/or anxiety. The psychological impact of the transition to motherhood, and the reorganisation of women’s roles, responsibilities, and priorities have also been previously identified as sources of stress and/or anxiety (Nelson Reference Nelson2003).
In line with previous research (Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016; Huschke et al., Reference Huschke, Murphy-Tighe and Barry2020), this study found that having a history of maternal mental health issues was significantly associated with higher levels of perinatal anxiety. Identification of women who are at increased risk due to previous mental health issues, and other factors identified in this study such as experiencing a high-risk pregnancy, is therefore essential. However, previous research has found that healthcare professionals feel they have inadequate skills and training to identify and provide suitable mental health supports and interventions (Pope et al., Reference Pope, Redsell, Houghton and Matvienko-Sikar2023). In addition, in the current study, women felt ill-informed about mental health issues and unable to identify when they required additional support. Women also described feeling abandoned, isolated, and uncared for, particularly in the postnatal period. A perceived reduction in support following the birth of their baby suggests a discrepancy between women’s needs and the support available within the healthcare service. Women’s perceptions of inadequate availability of mental health care in this study are consistent with existing research on Irish Perinatal Mental Health Services, which concluded that the current care provision service is ‘insufficient’ to meet women’s mental health needs (Huschke et al., Reference Huschke, Murphy-Tighe and Barry2020, p. 6). This combination of healthcare professionals’ perceived constraints and lack of information provision for women increases the likelihood of failure to identify when women require additional support.
To overcome such issues, increased support, training, and awareness for healthcare professionals providing maternity care, with increased availability and provision of information is needed to better support women during the perinatal period (Pope et al., Reference Pope, Redsell, Houghton and Matvienko-Sikar2023). Dedicated healthcare appointments for maternal healthcare issues were also suggested by women as potentially helpful, particularly postnatally. Providing a centralised source of support women can refer to was recommended for future development, such as, for instance, the Specialist Perinatal Mental Health Services and Perinatal Mental Health app that is currently targeted for development (Health Service Executive 2023). Our findings indicated that such digital resources, coupled with the availability of in-person healthcare supports, are needed.
In addition to the provision of external services and supports, this study identified several positive, proactive psychological and behavioural factors that women felt helped reduce perinatal stress and/or anxiety. For instance, higher levels of resilience were associated with lower stress and/or anxiety, indicating an important psychological construct that can be fostered to support perinatal mental health (Saur and Dos Santos Reference Saur and Dos Santos2021). Using self-care strategies such as exercise, relaxation techniques, and holistic therapies was also described by women in this study across the perinatal period. Previous research on the effects of such strategies for perinatal stress and/or anxiety has demonstrated inconsistent findings; however, methodological limitations of individual studies have been noted, for example (Beddoe and Lee Reference Beddoe and Lee2008; Davenport et al., Reference Davenport, Ruchat, Poitras, Jaramillo Garcia, Gray and Barrowman2018; Evans et al., Reference Evans, Morrell and Spiby2018; Hall et al., Reference Hall, Beattie, Lau, East and Anne Biro2016; Matvienko-Sikar et al., Reference Matvienko-Sikar, Redsell and Flannery2023, Reference Matvienko-Sikar, Flannery, Redsell, Hayes, Kearney and Huizink2021). Robust future research is warranted to determine the impact of such strategies and activities that women already engage in and describe as beneficial. In particular, research with women from lower socio-economic groups and/or marginalised communities, who may experience differing psychological outcomes and self-care strategies is needed.
Strengths and limitations
Women in this study were predominantly Irish nationals, married or in a relationship, and educated to degree levels or higher, which limits the generalisability of our findings beyond the sample included in this study. As such, differential experiences and support needs of disadvantaged and/or marginalised communities (Suwalska et al., Reference Suwalska, Napierała, Bogdański, Łojko, Wszołek, Suchowiak and Suwalska2021) may have been missed, and offer an important avenue for future research. Participant ethnicity or length of time living in Ireland was also not collected, and as a result, the varied experiences of minority ethnic groups and/or immigrants to Ireland were not explored, which limits the generalisability of our findings. However, our findings are comparable to those from the broader international literature (Bayrampour et al., Reference Bayrampour, Vinturache, Hetherington, Lorenzetti and Tough2018; McCarthy et al., Reference McCarthy, Houghton and Matvienko-Sikar2021), indicating applicability beyond the Irish and sample-specific context of this study. In addition, it was not possible to investigate some social and demographic risk factors of stress and anxiety (e.g. smoking) due to low variability within the sample. This study did not specifically examine the role of current mental health diagnoses and/or depression on study outcomes, future research examining these factors would be beneficial to expand on the current findings. Similarly, we did not examine the influence of whether women were linked with perinatal or community mental health services, and/or whether they were receiving pharmaceutical or psychological support for stress and/or anxiety, as this information was not collected; thus representing an opportunity for further research. Despite these limitations strengths of the study include the mixed-methods approach that enabled the examination of both quantitative factors that contribute to stress and anxiety and participants’ qualitative lived experiences. The large sample size and overall high completion rate of qualitative questions are also a strength of the study, enabling a comprehensive examination of sources and experiences of stress and anxiety and needs and preferences for perinatal mental health supports.
Conclusion
The findings demonstrate women’s experiences and perceptions of perinatal stress and anxiety, as well as what women find supportive, or not, during the perinatal period. Overall, women want greater support during the period as they often feel abandoned and alone in their experiences. At an interpersonal level, women value support from partners, friends, family, and support groups of others going through similar experiences. At a service level, women want more support from the healthcare services and greater contact with healthcare professionals, particularly in the postpartum period. Women want this contact to focus on their own health and well-being needs, along with the needs of their babies. This study also highlights the importance of building on the positive proactive supports women already engage in and find helpful, including fostering resilience and allowing women the time and space to engage in self-care. Development of support-based interventions and interventions based on positive support for reducing stress and anxiety across the perinatal period are needed. This must be coupled with improvements to service provision across the perinatal period to better support women at a population level.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ipm.2024.52.
Financial support
This work was supported by the Health Research Board (grant number: HRB-ARPP-A-2008-011).
Competing interests
The author(s) declare none.
Ethical standard
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval for the study was granted by the University College Cork Social Research Ethics Committee (Log 2022-245).
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