Mr Akash Srinivasan BSc (Hons)
School of Medicine
Imperial College London
Level 2, Faculty Building
South Kensington Campus
London SW7 2AZ, UK
akash.srinivasan17@imperial.ac.uk
07555373478
Dear Editor,
We read with interest the recently published article by Hulsbosch et al,
which investigated an association between co-morbid anxiety and
depression (CAD) symptoms during pregnancy, and the likelihood of a
physiological birth (defined as birth at term free from intervention
during labour, with a healthy mother and baby). This prospective
longitudinal cohort study used validated depression and anxiety scales
completed by participants at each trimester of their pregnancy to group
them into three categories depending on the frequency of high CAD
levels. The study found that there was a significantly lower rate of
physiological births in the group with persistently high levels of CAD
symptoms levels compared to those with persistently low level of CAD
symptoms.
The study achieves novelty in its investigation of both depression and
anxiety and their implications for physiological births. Figure S2
reveals that within the group with “persistently high levels of CAD
symptoms”, some women had reducing anxiety alongside increasing
depression, and vice versa, showing the importance of viewing these two
symptoms in tandem.
Although important confounders were considered, including complications
in pregnancy being studied, previous traumatic births were not accounted
for or discussed. Evidence suggests that having previous traumatic
births can both increase both depression and anxiety, and also increase
the risk of future non-physiological births, in subsequent pregnancies.
It would therefore be pertinent to ensure that the “persistently
anxious” group did not have a history of traumatic childbirth.
The authors discuss the possibility that CAD symptoms in pregnancy may
alter the release of stress hormones to cause an effect on labour, which
may reduce the physiological birth rate. It must be noted that the
studies cited to support this all refer to stress hormone levels after
the onset of labour, and to our knowledge there are no studies
investigating antenatal stress hormone levels and their association with
physiological births. Given that this was a prospective study,
intrapartum anxiety levels could have been assessed to examine whether
antenatal anxiety indeed affects physiological birth rate independent of
intrapartum anxiety. The alternate hypothesis for why women with high
levels of CAD may have reduced physiological birth was that women with
persistent CAD levels may have reduced self-efficacy. This could be
further explored by determining from the notes whether the interventions
that rendered the birth non-physiological were medically required, or
mainly the choice of the patient.
In conclusion, this article provides an interesting insight into how a
woman’s mental wellbeing during pregnancy may affect their physical
birthing outcome. It did so in a large population and used data across
all trimesters of pregnancy using validated scales. However, important
confounders required discussion, particularly relating to previous
birthing experiences for multiparous women. Furthermore, to provide more
useful clinical information, such as whether self-efficacy surrounding
natural childbirth should be focused on in antenatal counselling for
women with persistent CAD symptoms, more information about the woman’s
intrapartum anxiety, and what made the births non-physiological, could
have been collected.