Understanding and measuring pregnancy-related anxiety in low- and middle-income contexts: A pilot study in northern Ghana

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Background Women's anxiety during pregnancy is widespread and has been associated with poor mental and physical health outcomes for both mothers and their children. One type of anxiety which seems to be particularly problematic is anxiety about the pregnancy itself. We know little about this type of anxiety in low- and middle-income countries (LMICs). However, what we do know suggests that pregnancy-related anxiety may differ for women in LMICs as compared to women in high-income countries: women in LMICs are more concerned about healthcare access, disease, and maternal mortality. Despite these differences in pregnancy-related anxiety between high-income and LMIC contexts, no measures of this construct have been validated in any LMIC. Together, this suggests that: 1) maternal mortality may be more important to the pregnancy-related anxiety of women in LMICs, 2) there is variation in domains of pregnancy-related anxiety in different contexts, and 3) the scales which are developed to measure pregnancy-related anxiety in pregnant women in high-income countries may not be effective in measuring this anxiety in women in LMICs because they may not be capturing all locally-relevant components of this anxiety. Objectives The proposed project will address this through the following research questions: 1. How do levels of pregnancy-related anxiety differ by region and by maternal and neonatal mortality rates?2. How is pregnancy-related anxiety conceptualized in the northern Ghanaian context?3. How can we effectively measure pregnancy-related anxiety in the Northern Region of Ghana?To answer these questions, we will first systematically review research on prenatal anxiety. This will allow us to get a clear overview of levels of pregnancy-related anxiety, including clarifying geographic gaps in our knowledge and understanding its links with mortality. We will then apply a bottom-up approach, using focus group discussions with 150 women to investigate the domains of pregnancy-related anxiety in Ghanaian women. We will use this enhanced understanding to inform the adaptation of the Pregnancy-Related Anxiety Scale. We will adapt this measure to context and then validate it using a survey study of 575 pregnant women in northern Ghana. This culturally-adapted measure will allow for more accurate and reliable screening for pregnancy-related anxiety in Ghanaian women. We will use Northern Region of Ghana as an exemplar in addressing Objectives 2 and 3. We have chosen this location because: 1) Symptoms of anxiety are common among pregnant Ghanaian women, with 11% having a generalized anxiety disorder.2) Rates of maternal and neonatal mortality are high in this Region. Understanding - and ultimately, addressing - their mental health during pregnancy has the potential lead to reductions in these rates.3) 97.7% of women in the Northern Region receive antenatal care. Interventions to reduce pregnancy-related anxiety are commonly conducted in healthcare settings, and so this Region is well-suited for future intervention work.4) Our study team have a number of collaborations together in this Region, and thus are well-placed to deliver this project. Significance The outcome of this project will be a clearer understanding what underlies pregnancy-related anxiety and how to accurately measure it in LMIC contexts. Without a clear understanding of what underlies this anxiety, we cannot develop effective interventions, and without good measures of this anxiety, we cannot test whether those interventions are effective. This project directly addresses both of those issues and thus will pave the way for future work promoting mental health and wellbeing during pregnancy and reducing associated maternal mortality and morbidity. It is clearly aligned with the UN Sustainable Development Goal #3 of promoting health and wellbeing.