Anxiety measures validated in perinatal populations: A systematic review

“…1978); RDC = Research Diagnostic Criteria; CIS = Clinical Interview Schedule (Goldberg et al., 1970); HRSD = Hamilton Rating Scale for Depression (Hamilton, 1960); PSE = Present State Examination (Wing et al., 1974); PAS = Psychiatric Assessment Schedule; SPI = Standardised Psychiatric Interview.”

“Sample:PC = primary care e.g. women at antenatal clinic; R = subsample of a research study; C = community Self-report instruments: CC-D&A = Trait anxiety & depression scales (Costello & Comrey, 1967); BAI = Beck Anxiety Inventory (Beck & Steer, 1991); BDI = Beck Depression Inventory (Beck, 1961); ENES = Eysenck Neurot…”

“…has shown robust psychometric properties in non-perinatal samples and had substantially better validity coefficients than the GHQ-12 in discriminating cases of anxiety and mood disorders in the Australian National Survey of Mental Health and Well-being (Kessler et al., 2002; Furukawa et al., 2003).”

“Only the GHQ-28 has a specific anxiety subscale.”

“…that DASS and DASS-21 scores discriminated between diagnoses of major depressive disorder, panic disorder, social anxiety disorder , obsessive compulsive disorder and specific phobia; and there is a clear three-factor structure with items loading onto the expected factors (Antony et al., 1998).”

“Self-report measures of a construct should correlate more highly with another measure of the same construct, than with a purported measure of a different construct (Watson et al., 2008, Clark and Watson, 1991).”

“%) in Goldberg et al. (1997).”

“Six and four item versions of the state scale of the STAI have been constructed and validated for use in pregnant populations (Marteau and Bekker, 1992).”

“The scale was designed to include minimal reference to somatic symptoms (Snaith, 2003).”

“…has shown robust psychometric properties in non-perinatal samples and had substantially better validity coefficients than the GHQ-12 in discriminating cases of anxiety and mood disorders in the Australian National Survey of Mental Health and Well-being (Kessler et al., 2002; Furukawa et al., 2003).”

“In a UK study of 8,323 women, 13% of women reported anxiety symptoms at either eight weeks or eight months postpartum and of these two-thirds had experienced anxiety in pregnancy (Heron et al., 2004).”

“Validity of any self-report measure depends on recalibration for the population under study (Geisinger, 1994).”

“However, the utility of the EPDS appears to vary in different samples (Gibson et al., 2009) and there is evidence that the EPDS has three items that also measure anxiety.”

“A large prospective study (n = 12,361) confirms that antenatal anxiety is one of the strongest predictors of postnatal depression indicating that antenatal screening for anxiety may be helpful in reaching women at risk of postnatal depression (Milgrom et al., 2008).”

“The Hopkins-Symptom Checklist 25 (Derogatis et al., 1974) is a self-report inventory of 10 anxiety and 15 depression items derived from the SCL-90.”

“54 5th month postnatal (1994a) 50.0 84.3 - - - (Nott & Cutts, 1982) Unmodified 6/7 80 89 50 97 19 Author modified 6/7 83 87 53 96 16 (Sharp, 1988)a 5/6 77 78 52 96 22 Note: aClinical Interview Schedule cut-off point of 17/18; bSampling strategy prohibited calculation of positive predictive value, therefore the authors…”

“Firstly, the Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007) is a new multi-dimensional measure of symptoms of anxiety and depression, containing 64 items which yielded 10 factors in multiple samples relating to symptoms of: suicidality, lassitude (fatigue, lack of energy,…”

“Although prevalence data of anxiety disorders is limited, a review tentatively suggests that rates of OCD and GAD are higher in perinatal populations than in the general population, whilst rates of panic disorder and posttraumatic stress disorder (PTSD) are comparable (Ross and McLean, 2006).”

“Pregnancy specific stress has predicted poor birth outcomes better than state anxiety and perceived stress (Lobel et al., 2008).”

“…linked with intrauterine artery resistance leading to low birthweight (Teixeira et al., 2009; Field et al., 2010), low apgar scores (Berle et al., 2005), suboptimal changes in fetal heart rate and motor activity (DiPietro, 2010) and complications of labour and delivery (Johnson and Slade, 2003).”

“In two samples of women interviewed at 6 weeks postpartum Matthey et al. (2003) found 16.2% and 10.4% of women had anxiety disorders only, whereas 5.6% and 2.6% had major or minor depression only, and 4.2% and 2.1% had comorbid depression and anxiety highlighting the importance of screening for…”

“Quality of studies was assessed using a combined checklist based on the quality assessment of diagnostic accuracy studies (QUADAS) (Whiting et al., 2003) and a checklist developed by Mirza and Jenkins (2004).”

“In general, internal consistency is good, ranging from 0.91 – 0.95 for the state subscale of the full version (Marteau and Bekker, 1992; Grant et al., 2008) and 0.82 for the 6 item version (Marteau and Bekker, 1992).”

“Test-retest reliability (the ability of a test to yield consistent scores over time) should be greater than .80 over one to two weeks or .70 or greater over one month (Boyd et al., 2005).”

“A study using diagnostic interviews with women eight weeks postpartum found 8.2% of women had generalized anxiety disorder (GAD), 2.7% had obsessive compulsive disorder (OCD), 1.4% had panic disorder and 4.1% social anxiety disorder (Wenzel et al., 2005).”

“…review indicates that postnatal maternal anxiety is associated with deleterious outcomes for children such as alterations in emotional and conduct problems, and adverse effects on cognitive and social developments, although effects on infant temperament are inconclusive (Glasheen et al., 2010).”

“…women at antenatal clinic; R = subsample of a research study; C = community Self-report instruments: CC-D&A = Trait anxiety & depression scales (Costello & Comrey, 1967); BAI = Beck Anxiety Inventory (Beck & Steer, 1991); BDI = Beck Depression Inventory (Beck, 1961); ENES = Eysenck Neuroticism…”

“Prenatal anxiety has been linked with intrauterine artery resistance leading to low birthweight (Teixeira et al., 2009; Field et al., 2010), low apgar scores (Berle et al., 2005), suboptimal changes in fetal heart rate and motor activity (DiPietro, 2010) and complications of labour and delivery…”

“One study shows that women with anxiety disorders in pregnancy are nearly three times more likely to present with postnatal depression (Sutter-Dallay et al., 2004).”

“34 weeks gestation HADS - Factorial Test-retest Internal consistency 8 Kitamura et al., 1989d 13 Japan 108 PC Antenatal 12 weeks gestation GHQ-30 SADS (RDC) Criterion: Sens, Spec, MR, PPV, NPV Discriminant Function Analysis - 8 Kitamura et al., 1993d 14 Japan 108 PC Antenatal 12 weeks gestation GHQ-30 - Compared 4 dif…”

“Cut-offs used in perinatal studies ranged from 5 in a Nigerian sample (Abiodun, 1993) to 7/8 in a Japanese sample (Kitamura et al., 1989, 1994a, 1994b).”

“Longer term effects of high antenatal anxiety can include externalizing problems and self-reported anxiety at ages 8-9 (Van den Bergh and Marcoen, 2004) and high impulsivity and lower scores on cognitive tests at ages 14-15 (Van den Bergh et al., 2005).”

“A number of measures have been developed that are specific to pregnancy and consider aspects related to anxiety such as worry or daily hassles but do not measure anxiety itself (Cambridge Worry Scale: Green et al., 2003; Pregnancy Experience Scale: DiPietro et al., 2004).”

“There is also evidence that the depression subscale of the EPDS correlates more highly with other measures of anxiety than the anxiety subscale does, indicating poor convergent validity (Brouwers et al., 2001).”

“Self-report measures of a construct should correlate more highly with another measure of the same construct, than with a purported measure of a different construct (Watson et al., 2008, Clark and Watson, 1991).”

“A number of measures have been developed that are specific to pregnancy and consider aspects related to anxiety such as worry or daily hassles but do not measure anxiety itself (Cambridge Worry Scale: Green et al., 2003; Pregnancy Experience Scale: DiPietro et al., 2004).”

“…has been linked with intrauterine artery resistance leading to low birthweight (Teixeira et al., 2009; Field et al., 2010), low apgar scores (Berle et al., 2005), suboptimal changes in fetal heart rate and motor activity (DiPietro, 2010) and complications of labour and delivery (Johnson and…”

“Reliability is a measure of the properties of a test within a particular sample rather than a property of a test per se and therefore should be computed in each sample (Vacha-Haase et al., 2000).”

“Clinician judgement and use of the gold standard will also have an effect on the utility of validity coefficients (Joiner et al., 2005).”

“Therefore an evaluation must be made as to whether the sample with whom the test was designed is sufficiently similar to the test sample to ensure little variability in functioning of the self-report measure (Myers and Winters, 2002).”

“A Dutch study improved the ability of the K10 to identify anxiety disorders by adding five further items pertaining to GAD, social anxiety disorder, panic and agoraphobia (Donker et al., 2010).”

“5% of women reported intense anxiety or panic attacks occasionally or often between 6 and 9 months postpartum in a computer assisted telephone interview (Woolhouse et al., 2009).”

“…linked with intrauterine artery resistance leading to low birthweight (Teixeira et al., 2009; Field et al., 2010), low apgar scores (Berle et al., 2005), suboptimal changes in fetal heart rate and motor activity (DiPietro, 2010) and complications of labour and delivery (Johnson and Slade, 2003).”

“For example, the EPDS is used as a measure of depression but evidence suggests a few items on the EPDS measure anxiety (Phillips et al., 2009; Jomeen and Martin, 2005).”

“The EPDS and GHQ-12 showed good concurrent validity (r = 0.80) (Navarro et al., 2007).”

“In a sample of women in early pregnancy the K-10 identified 69 - 76% of diagnosed cases of anxiety disorders (Spies et al., 2009).”

“…linked with intrauterine artery resistance leading to low birthweight (Teixeira et al., 2009; Field et al., 2010), low apgar scores (Berle et al., 2005), suboptimal changes in fetal heart rate and motor activity (DiPietro, 2010) and complications of labour and delivery (Johnson and Slade, 2003).”

“Sample:PC = primary care e.g. women at antenatal clinic; R = subsample of a research study; C = community Self-report instruments: CC-D&A = Trait anxiety & depression scales (Costello & Comrey, 1967); BAI = Beck Anxiety Inventory (Beck & Steer, 1991); BDI = Beck Depression Inventory (Beck, 1961); ENES = Eysenck Neurot…”

“Barnett and Parker (1986) reported further discriminant validity through inspection of hospital files where nursing staff considered a significantly higher percentage of women in the high anxiety group to have ‘mood problems’ than in the moderate or low anxiety groups.”

“There is also preliminary evidence that a further proportion of women experience clinically significant anxiety symptoms that do not fit into DSM-IV anxiety diagnoses (Phillips et al., 2009).”

“1 month postnatal Kitamura et al., 1994bd 16 Japan 108 PC Antenatal i.1st trimester ii.3rd trimester GHQ-30 SADS (RDC) Criterion: Sens, Spec, MR, PPV, NPV - 9 Levin, 1991 17 USA 266 PC Postnatal measurement of antenatal anxiety i.After birth whilst mothers still in hospital Pregnancy Anxiety Scale (PAS) - Factorial -…”

“Research into perinatal anxiety uses a variety of self-report measures including the State Trait Anxiety Inventory (STAI; Spielberger et al., 1970), Crown-Crisp Experiential Index (Crisp et al., 1978) and Beck Anxiety Inventory (Beck et al., 1988).”

“Self-report measures created for use in populations in western countries are often validated for use in different languages and cultures (Prince, 2008).”

“In a small sample of 3 or 6 month postpartum women the SCL-90-R anxiety subscale scores distinguished women with anxiety disorders from women with no psychiatric diagnosis but did not distinguish anxiety cases from depression cases in post-hoc tests (Muzik et al., 2000).”

“…2nd HADS - Factorial Concurrent Internal consistency 8 trimester EPDS Kaaya et al., 2002 11 Tanzania 903 R Antenatal 8-26 weeks gestation HSCL-25 SF-36 SCID (DSM-IV) Factorial Concurrent Internal consistency 10 Karimova & Martin, 2003 12 UK, Uzbekista n 100 PC Antenatal i.12 weeks gestation ii.”

“However a Japanese study in pregnancy and at different time points postpartum found no cut-off yielded satisfactory sensitivity (Kitamura et al., 1994a).”

“3% of whom had substantially lower trait scores at 3 months postpartum than at 2-3 days postpartum (Giakoumaki et al., 2009).”

“Jomeen and Martin (2004) carried out principal components analysis (PCA) and confirmatory factor analysis (CFA).”

“There is also preliminary evidence that a further proportion of women experience clinically significant anxiety symptoms that do not fit into DSM-IV anxiety diagnoses (Phillips et al., 2009).”

“34 weeks gestation HADS - Factorial Test-retest Internal consistency 8 Kitamura et al., 1989d 13 Japan 108 PC Antenatal 12 weeks gestation GHQ-30 SADS (RDC) Criterion: Sens, Spec, MR, PPV, NPV Discriminant Function Analysis - 8 Kitamura et al., 1993d 14 Japan 108 PC Antenatal 12 weeks…”

“Aderibigbe & Gureje, 1992b 4 Nigeria 277 PC Antenatal Late 2nd –early 3rd trimester GHQ-28 PAS (DSM-III-R) Criterion: Sens, Spec, MR, PPV, NPV Concurrent Compared 2 different scoring methods Discriminant Function Analysis - 8 Barnett & Parker, 1985c 5 Australia 147 PC Postnatal i. 3-4 days ii.”

“One study found that the C-GHQ method of scoring resulted in higher sensitivity and specificity than the standard GHQ scoring in Nigerian women in the late second or early third trimester (Aderibigbe and Gureje, 1992).”

“For example the STAI has been used in perinatal samples with cut-offs of >40 (Grant et al., 2008) to >45 (Moss et al., 2009) or >48 (Field et al., 2010) to indicate disorder, without prior validation in this population.”

“Sample:PC = primary care e.g. women at antenatal clinic; R = subsample of a research study; C = community Self-report instruments: CC-D&A = Trait anxiety & depression scales (Costello & Comrey, 1967); BAI = Beck Anxiety Inventory (Beck & Steer, 1991); BDI = Beck Depression Inventory (Beck, 1961); ENES = Eysenck Neurot…”

“Anxiety disorders and subthreshold anxiety symptoms can be detrimental to the mother-infant relationship (Zelkowitz and Papageorgiou, 2005).”

“Hundley et al (1998) found test-retest correlations of between 0.37 - 0.85 on the trait scale.”

“The shorter versions of the GHQ do not result in greatly reduced sensitivity and specificity in non-perinatal populations (Ayers, 2001).”

“The K10 may be the best short screening measure due to its ability, over the GHQ-12, to differentiate anxiety disorders.”

“…9 Sagrestano et al., 2001 25 USA 166 PC Antenatal >20 weeks gestation PSAI (single items) STAI - Concurrent Discriminant Internal consistency 9 Sharp, 1988 26 UK 179 PC Antenatal 20 weeks gestation GHQ-30 CIS Criterion: Sens, spec, MR, PPV - 9 Spies et al., 2001 27 South Africa 129 PC…”

“One study found that the C-GHQ method of scoring resulted in higher sensitivity and specificity than the standard GHQ scoring in Nigerian women in the late second or early third trimester (Aderibigbe and Gureje, 1992).”

“…was constructed through an internet survey of 142 questions derived from case descriptions of postnatal psychiatric disturbance and DSM-IV-R, with participants asked to retrospectively rate the frequency with which they experienced symptoms in the first 30 days after birth (Marrs et al., 2009).”

“Factor analysis in a non-perinatal population suggests the scale may be measuring one latent factor rather than two distinct anxiety and depression subscales (Shevlin et al., 1998).”

“However a Japanese study in pregnancy and at different time points postpartum found no cut-off yielded satisfactory sensitivity (Kitamura et al., 1994a).”

“34 weeks gestation HADS - Factorial Test-retest Internal consistency 8 Kitamura et al., 1989d 13 Japan 108 PC Antenatal 12 weeks gestation GHQ-30 SADS (RDC) Criterion: Sens, Spec, MR, PPV, NPV Discriminant Function Analysis - 8 Kitamura et al., 1993d 14 Japan 108 PC Antenatal 12 weeks gestation GHQ-30 - Compared 4 dif…”

“66 Self-report measures do have limitations, such as potentially inflated prevalence estimates, but they also have high clinical utility in obstetric/midwifery, public health and primary care practices, where the majority of perinatal mental health problems are managed.”

“Although the prevalence of maternal anxiety during pregnancy is heterogeneous, anxiety symptoms and disorders are common in the perinatal period (Meades and Ayers, 2011; Ross and McLean, 2006; Giardinelli et al., 2012).”

“The Spielberger STAI has been validated in for use in perinatal populations.(22) Population normative data shows that the median score for both state and trait anxiety among women ages 19–39 is 34.”

“The reviewers restated the need for a welleloped scale with a rigorous theoretical and psychotric basis for the assessment of PrA, a need that has also n identified by other experts in the field (Brunton et al., 5; Littleton et al., 2007; Meades and Ayers, 2011).”

“, 2014; Van den Bergh, 1990), and several reviews of the research literature exist (Alderdice et al., 2012; Brunton et al., 2015; Dunkel Schetter and Tanner, 2012; Meades and Ayers, 2011).”

“To investigate the structure of specific fears and worries related to the postpartum period (‘postpartum anxieties’) using this new scale 1 For a comprehensive review of anxiety measures validated in perinatal populations, refer to Meades and Ayers (2011)”

“The STAI-State has demonstrated reliability and validity and has been used widely in pregnancy and postpartum studies (Grant et al., 2008; Meades and Ayers, 2011).”

“The effect sizes were expressed as Cohen d or standardized mean difference, which were interpreted as small (0.2 d 0.5), medium (0.5 d 0.8), and large ( d ≥0.8) [43].”

“30 This four-point Likert-type scale includes 40 items to assess state and trait anxiety, with 20 items in each subscale.”

“State anxiety was measured with the Dutch adaptation of the State-Trait Anxiety Inventory (STAI; Spielberger et al. 1970) at t1-t3, which has been shown to be a reliable and valid measure in general populations but also in pregnancy (Gunning et al. 2010; Meades and Ayers 2011).”

“These unique aspects may affect responses on self-report measures which include items that are not appropriate for the postnatal period [10].”

“This scale has been validated against clinical interviews during both the pregnancy and postpartum period and has been found to have acceptable sensitivity, specificity, and predictive values to determine cases of anxiety among a perinatal population (Grant et al., 2008; Meades and Ayers, 2011).”

“The Spielberger State and Trait Anxiety Inventory (STAI)—The Spielberger State and Trait Anxiety Inventory (STAI), a validated instrument used to assess anxiety and validated for use in the perinatal population, (Meades and Ayers, 2011) was administered at enrollment during the third trimester, as well as at the 2- an…”

“An overlap between depression and anxiety symptoms has been consistently recognized (e.g., Kennedy et al., 2001; Meades & Ayers, 2011).”

“34 The PHQ-9 is a self-administered questionnaire which asks respondents to rate the frequency of nine Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition depression criteria from 0 (‘‘not at all’’) to 3 (‘‘nearly every day’’) for a score range of 0 to 27.”

“Therefore, specific measures for anxiety in the perinatal period are strongly recommended [4,5].”

“The association between a birth with complications and PTSD has been reported before (Ayers and Pickering, 2001; Ayers, 2004; Olde et al., 2006; Meades and Ayers, 2011).”

“While each of the scales used has been previously shown to be associated with clinical diagnosis, the lack of confirmation by a mental health professional limits our ability to confirm comorbid diagnoses (Kroenke et al. 2001;Meades and Ayers 2011; Rosenfeld et al. 1992).”

“In regard to the perinatal population, the State-Trait Anxiety Inventory has been shown to have construct validity (30).”

“The STAI is a self-reported series of questions pertaining to frequency of various symptoms of state or trait anxiety.(16) A score of more than 100 (of 160) defines a positive screen.”

“Previous researches have shown a high prevalence of psychiatric illness in pregnant women [1,2], not only in the developed countries, but also in developing countries such as Turkey [3].”

“The GAD-7 has been validated in western primary care, but not in antepartum populations or in African settings, as research in antepartum anxiety is still in its early stages [14,15].”

“This cut off score was calculated using the same cut-off ratio as the original STAI, >40/80.(31) Using these dichotomous variables for cases of depression and anxiety, univariate analysis was performed to examine associations between depression and anxiety and the women’s socio-demographic, socio-economic, pregnancy a…”

“There is increasing evidence of the detrimental role anxiety may play in pregnancy and the importance of screening for anxiety (Matthey et al. 2012; Meades and Ayers 2011); however, this study did not include a clinical measure of anxiety and, hence, the performance of the three-item anxiety…”

“The STAI has acceptable sensitivity, specificity, and predictive values during the perinatal period.(31,32) Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-reported questionnaire.”

“This research was supported by Grant 400-09-123 from the Netherlands Organization for Scientific Research and a grant from the foundation Stichting tot Steun Nederland.”

“State anxiety was selected for modeling, as it is more amenable to temporal fluctuation and less analogous to stable personality traits (Spielberger 2010) and its use has been validated in perinatal studies (Meades and Ayers 2011).”

“Most antenatal anxiety measures have been adapted from general health questionnaires with very few validated for use in pregnancy (Meades & Ayers 2011).”

“The STAI-T has been validated for use in perinatal populations (Meades & Ayers, 2011).”

“Based on such results, it may be argued that perinatal screening programs should include the detection of women with high levels of anxiety [3, 11].”

“And Meades and Ayers [45] referred to cultural or psychometric factors contributing to problems with the internal consistency, factor-structures and cutpoints.”

“This may lead to erroneous data, inaccurate interpretation, and incomparable results across studies (Meades and Ayers 2011).”

“The STAI-S is a valid and reliable measure used frequently in perinatal samples of women [18].”

“…this risk factor category, stress and anxiety were measured in a variety of ways including self-report of distress, anxiety, and exposure to specific stressors; however, this variability in measurement is consistent with the measurement of perinatal anxiety in the field (Meades & Ayers, 2011).”

“The STAI has been shown to be a reliable and valid measure in both pregnancy and the postpartum period (Meades & Ayers, 2011) and has been validated in the”

“The results from studies examining possible temporal relationshipswere inconsistent as well (e.g. Çak et al. 2015;Miller et al. 1993), and it remainsunclear towhatextent these inconsistenciesmightbedue todifferences indesigns, definitions andmeasurements throughout pregnancy and early infancy.”

“The STAI is a widely used instrument for measuring anxiety in postpartum populations (Meades and Ayers, 2011).”

“There is a validated Malay language version of DASS-21[12]; the Malay language version has concurrent validity in anxiety and depression components in infertility patients[13] when compared to the Hospital Anxiety and Depression Scale which is validated in perinatal populations[14].”

“Third, although the questionnaires used to assess mental health and the physical fitness tests in this study were valid and reliable for the general population, their psychometric properties have not been extensively tested among pregnant women, except for the STAI-T, whose validity has been previously corroborated at…”

“The STAI shows strong criterion, discriminant, and predictive validity in perinatal populations (Meades and Ayers, 2011).”

“Previous research had reported that mothers in this situation were anxious and stressed (Erdem, 2010; Gueron-Sela et al., 2013; Meades & Ayers, 2011).”

“Nine studies and 1 systematic review (61) evaluated 12 screening instruments in pregnant and postpartum women.”

“The GAD-7 has been validated in western primary care, but not in antepartum populations or in African settings, as research in antepartum anxiety is still in its early stages [26,27].”

“The BDI score during pregnancy correlated highly with the BDI score at the infants’ age of three to four months (Spearman’s rho= 0.62; p , .001); the same was true for the STAI-S score (Spearman’s rho= 0.72; p , .001).”

“This scale has been validated for use in perinatal populations (Meades and Ayers, 2011), and was previously found to have an acceptable level of reliability in this population (Cronbach's α 0.64) (Redinger et al., 2018).”

“The STAI shows strong criterion, discriminant, and predictive validity in perinatal populations [46].”

“The STAI has been validated against clinical interviews during both pregnancy and the postpartum period and has been found to have acceptable sensitivity, specificity, and predictive values to identify cases of anxiety among the perinatal population [17,21].”

“The GAD-7 has been validated in western primary care, but not in African populations, as research in maternal anxiety in sub-Saharan Africa is still in its early stages [46,47].”

“, 2008) groups, and the scale has been widely used in studies of childbearing (Littleton et al., 2007; Meades and Ayers, 2011).”

“…is valid, but we acknowledge that these factors do not provide a complete picture of case conceptualization and it is important that measures are validated against a clinical conceptualization session or sessions, particularly when they are being used in a new population (Meades & Ayers, 2011).”

“At this time, women often experience mental and physical fatigue (Dennis and Ross 2005), disrupted sleep (Meades and Ayers 2011), mood disturbance, social isolation (O’Hara and Swain 1996), lowered self-esteem (Beck 2001), anxiety (including those related to parenting) and can subsequently lead to postnatal depression…”

“Furthermore, its criterion, discriminant and predictive validity [44], and ease of use can provide a reasonably accurate estimate of prevalence, and its widespread use in research studies [1,16] can enable more accurate comparisons among nations.”

“The STAI state subscale has good internal reliability and validity (Metzger, 1976; Okun, Stein, Bauman, & Silver, 1996; Spielberger et al., 1983), and have been shown to have good criterion, discriminant and predictive validity for perinatal populations (Meades & Ayers, 2011).”

“The total scale score ranges from 20 to 80, and a threshold of 45 has been used as an indicator of probable Generalised Anxiety Disorder or Adjustment Disorder in perinatal samples (Dennis, Janssen, & Singer, 2004; Figueiredo & Conde, 2011; Meades & Ayers, 2011).”

“The STAI has good validity and internal consistency in pregnant and postnatal populations (Meades & Ayers, 2011).”