The COVID-19 global pandemic context
The Coronavirus [SARS-CoV-2] or COVID-19 pandemic poses a devastating risk to the health of the global population. Amongst those thought to be most vulnerable are pregnant women and newborn infants, although guidance rapidly changed to state that pregnant women are no more vulnerable than the general population . Although the growing body of evidence remains conflicting about the size of the risk to these populations, perinatal deaths have been reported . This makes the perinatal period a time of increased vulnerability . Whilst COVID-19 poses a serious physical health risk to those who contract the virus, there is evidence for it also affecting mental health outcomes [4, 5]. Poor mental health in relation to COVID-19 has been associated with various Government mandated restrictions, which have been enforced in an attempt to slow the spread of the virus. These include ‘quarantine’ (the enforced isolation of persons with or suspected of having the virus) ; ‘social distancing’ (the physical separation of persons outside of those in one’s family) ; ‘lockdown’ (the closure of public venues and banning of non-essential travel) ; and ‘shielding’ (where the most vulnerable – including pregnant women – are advised to remain at home and leave under no circumstances) . Given the expected effect of the COVID-19 pandemic on mental health coupled with pregnant women and newborn infants being labelled as vulnerable groups , it is important to assess and understand the mental health effects in perinatal women . During normal circumstances, approximately 20% of all women who give birth are thought to experience mental health problems . The global pandemic is set to pose “unprecedented challenges that can significantly impact on women’s mental health” during the perinatal period , hence potentially driving these numbers even higher.
In 2014, the National Institute of Health and Care Excellence [NICE] requested attention to the under-detection of postpartum anxiety in recognition of the significant burden it poses . Postpartum anxiety is associated with many negative maternal and infant outcomes including reduced breastfeeding , reduced maternal sensitivity , impaired bonding , difficult infant temperament , atypical neurodevelopment , and child emotional and behavioural problems . However, general measures of anxiety are relied upon in a large majority of studies examining postpartum anxiety, but are psychometrically problematic [11, 18].
The Postpartum Specific Anxiety Scale [PSAS] examines the frequency of maternal and infant focused anxieties experienced by women across the first year of their infants’ life . The 51-item measure assesses four domains of anxiety, specific to the postpartum period. Factor 1 (Maternal Competence and Attachment Anxieties) contains 15-items which address anxieties relating to maternal self-efficacy, parenting competence, and the mother-infant relationship. Factor 2 (Infant Safety and Welfare Anxieties) has 11-items which relate to fears about infant illnesses, accidents, and cot death. Factor 3 (Practical Infant Care Anxieties) includes 7-items covering anxieties which are specific to infant care such as feeding, sleeping, and general routine. Finally, Factor 4 (Psychosocial Adjustment to Motherhood) contains 18-items which address adjustment concerns since the birth of the baby about management of personal appearance, relationships and support, work and finances, and sleep. Each answer is given a score of between 1 and 4 with the maximum score being a total of 204. Initial validation of the English-language version demonstrated a score of 112 or above may be indicative of a clinical level of anxiety .
The predictive validity of the measure has been examined and confirmed in relation to infant feeding outcomes and behaviours , and maternal bonding behaviours . Across both of these studies, the PSAS demonstrated stronger predictive power than a general non-childbearing measure of anxiety.
To date, initial validity and reliability has been demonstrated in one large UK sample , and more recently two Turkish samples [22, 23]. The English-language PSAS is currently being used throughout the UK, Canada, Australia, Ireland, Rwanda, and the USA. Translation of the PSAS has taken place in Italy, France, China, Spain, and The Netherlands, but are, as yet, unpublished. Further translations are currently ongoing in Brazil, Egypt, Germany, Greece, India, Indonesia, Iran, Iraq, Jordan, Malaysia, Portugal, and The Philippines. A further translation into Burmese (the language of Myanmar) is being undertaken by a research team in Thailand. (See Fig. 1).
Research to understand the psychological impact of COVID-19 in perinatal populations is critical in mitigating the severity of the outbreak. Rapid progress in addressing this pandemic depends upon a coherent and integrated response from researchers . There have also been global calls for the mental health sciences to work in a multi-disciplinary fashion to address the possible mental health crisis which may follow the physical health pandemic , and where possible make addressing mental health needs an integral part of the COVID-19 response . The 51-items in the PSAS take approximately 10 min for mothers to complete which, when integrated into a survey containing a battery of psychometric scales, may be burdensome, especially during the current pandemic, where specific populations may be over-sampled. Therefore, during times of crises such as the current COVID-19 global pandemic, it is desirable to use shortened measures, to reduce participant burden. Furthermore, to the authors’ knowledge, there have been no psychometric scales (including measures of perinatal mental health) validated for use during the current pandemic.
In the UK, NICE guidelines recommend psychometric measures should contain fewer than 12 items for optimal accessibility . This article reports the development of a 12-item research short-form of the PSAS, validated for use in global crises [PSAS-RSF-C]. The validation of the PSAS-RSF-C, in English, acts as a nested psychometric study within a larger on-line UK survey: PRegnancy and Motherhood during COVID-19 [The PRaM Study]. As the 51-item PSAS is currently undergoing multiple translations (all at various stages of validation), we also present, within this paper, the same 12 items, in five other languages (Italian, French, Chinese, Spanish, and Dutch). By increasing the accessibility of the PSAS, validated for use during COVID-19, we aim to enable researchers the opportunity to measure maternal anxiety, rapidly and accurately, at times of global crisis.