How do prenatal people describe their experiences with anxiety? a qualitative analysis of blog content

The first author (SP) used Google.com (United States) to search various combinations of the keywords pregnancy (prenatal, pregnant, pregnancy), anxiety (anxious, anxiety, stress) and blog (personal blog, blog). “Antenatal” was later added as another word for prenatal, as the bloggers commonly used this term. Previous research reveals that readers typically do not look at webpages beyond the third page of Google results [32]. Thus, we only analyzed blogs found on the first three pages of each search. Twenty-six open-access blog entries accessed in March 2017 were analyzed (see Table 1 for n per search). Blogs were written between 2011–2017. Through consultation with and approval to proceed from the University of Manitoba Research Ethics Board, formal submission of ethics and consent were not needed as blogs are publicly accessible. This study was performed with relevant guidelines and regulations. Quotes included within this manuscript have been labelled with a participant code.

The authors analyzed each blog entry to determine whether they met the following inclusion criteria: 1) Online public blog entries; 2) Written in English; 3) Describe personal experiences with prenatal anxiety; 4) 250 words at minimum to ensure sufficient data for analysis. Given the high comorbidity of perinatal depression and anxiety [33], blog entries describing depression and anxiety were included. Of the 26 resulting blog entries, 18 met inclusion criteria. Eight were excluded: five for having less than 250 words and three for focusing on postpartum experiences. Dialogue from the 18 useable blog entries was copied into a Microsoft Word document for analysis.

The included blog entries were written by 18 prenatal people who were experiencing prenatal anxiety. There was variation across blogs regarding which pregnancy was discussed (e.g., first, second, or third). Some of the prenatal people described their experiences with miscarriage(s) or labour complications in a previous pregnancy. Prenatal people varied in their pre-pregnancy experiences with anxiety. Participant characteristics that were mentioned by bloggers are reported in Table 2.

We completed a thematic analysis based on grounded theory principles, including the specific tenets of the coding process (e.g., specify levels of coding, memoing, etc.) [34, 35]. The identification of themes was achieved in three stages: initial coding, focused coding, and theoretical coding [36]. Initial coding involved the first (SP) and second authors (KR) independently coding each line with gerunds, in vivo codes, or direct quotes to allow us to stay as close as possible to the data and the processes being described by bloggers. Memoing was achieved during this stage by having each coder keep a coding journal to track coding decisions and preliminary thoughts regarding themes. Our coding became more conceptual as we progressed through the analysis of blog content, within the focused and theoretical coding stages. In the focused coding stage, conceptual codes were developed by comparing preliminary themes and grouping together themes from multiple blogs. During the theoretical coding stage, codes were refined and employed into a relational explanation of the main themes and subthemes emergent from the data. These stages were moved through reflexively rather than sequentially as new data was coded. Each coder keep a coding journal throughout, which acted as an audit trail for coding decisions. Coding challenges were reviewed and resolved collaboratively in line with previously established standards for rigorous qualitative research [35].

All bloggers discussed the ways their anxiety developed, which we categorized into three main etiological pathways: anxiety developing before pregnancy, during the current pregnancy, or related to a previous pregnancy. Many bloggers described having pre-existing non-perinatal anxiety and how their anxiety worsened throughout pregnancy (Table 3, quote 1). A few bloggers described developing anxiety during pregnancy, particularly during the first trimester (Table 3, quote 2). These bloggers mentioned that their anxiety levels only decreased after delivering their baby (Table 3, quote 3). Lastly, some bloggers described developing anxiety in their current pregnancy due to challenges encountered in a previous pregnancy, such as miscarriage(s) (Table 3, quote 4) or life-threatening complications during labour (Table 3, quote 5).

All bloggers discussed at least one trigger for their prenatal anxiety, with many describing multiple triggers. Triggers resulting in worsened anxiety included three subthemes: uncertainty, perceived lack of control, and guilt and shame for not having a “normal” pregnancy free of anxiety.

The bloggers described six areas of uncertainty: waiting for their first prenatal appointment, their baby’s health, their health, the possibility of miscarriage, the experience of labour, and how having a baby would impact their life. Many bloggers described feeling the most uncertain during their first trimester (Table 3, quote 6). Uncertainty sprouted from having to wait 8–10 weeks into their pregnancy for their first prenatal appointment (Table 3, quote 7) and uncertainty around their baby’s health. Health concerns included their babies’ development, rare medical conditions that their baby might have, and symptoms that might indicate pregnancy complications (e.g., abdominal cramps creating concern of ectopic pregnancy). The mere thought of their baby not being healthy triggered anxiety (Table 3, quote 8). Additionally, many bloggers discussed how uncertainty around how the changes occurring to their body would impact their physical health triggered their anxiety (e.g., difficulty breathing as their stomach grows throughout pregnancy; Table 3, quote 9).

A few bloggers discussed how the fear of miscarriage triggered their anxiety. For some, this fear pertained to whether their regular activities, such as sleep, would harm their developing baby or even cause a miscarriage (Table 3, quote 10). For others, this fear involved previously experiencing a miscarriage (Table 3, quote 11). Thoughts regarding the experience of labour also triggered anxiety (Table 3, quote 12). For one blogger, this was due to their experience in their previous labour (Table 3, quote 13). Lastly, many bloggers expressed uncertainty regarding how having a baby would affect aspects of their lives, including their relationships, finances, and whether they could learn how to be a parent (Table 3, quote 14).

Related to the aforementioned areas of uncertainty, many bloggers expressed a perceived lack of control over their privacy, their choices regarding labour and delivery procedures, the various changes happening to their bodies, and their anxiety during their pregnancy. Regardless of the cause, bloggers expressed that their perceived lack of control increased their prenatal anxiety. Concerning privacy, one blogger described feeling attacked in social interactions when asked intrusive questions about their pregnancy (Table 3, quote 18). Some bloggers expressed feeling a lack of control over their bodies, particularly over choices related to labour and delivery procedures (e.g., whether to have an unmedicated or medicated labour and delivery; Table 3, quote 19), the changes occurring to their bodies to support the developing fetus (Table 3, quote 20), and deciding whether to continue their pregnancy (Table 3, quote 21). Lastly, a few bloggers described feeling they lacked control over their anxiety during pregnancy, referring to it as negative and uncontrollable (Table 3, quote 22). For a few bloggers, their anxiety elicited such distress that they felt that termination of the pregnancy or suicide was their only option (Table 3, quote 23).

A few bloggers elaborated on the stigma surrounding what emotions prenatal people ‘should’ feel during pregnancy (Table 3, quote 15). Bloggers described how experiencing negative emotions during pregnancy, rather than the expected positive emotions, triggered their anxiety. Many felt guilt and shame for not having a “normal” pregnancy filled with positive emotions (Table 3, 16). For a few bloggers, this guilt and shame led them to question whether they would be good mothers (Table 3, quote 17).

Discussion of the symptoms of anxiety that bloggers experienced during pregnancy revealed two categories of symptoms commonly experienced during the first trimester: 1) An inter-woven experience of emotions, thoughts, and physical symptoms; and 2) Behavioural symptoms. Emotions and thoughts described by bloggers included feeling selfish, negative, guilty, ashamed, embarrassed, disconnected, fretful, worried, impatient, and intolerant (Table 3, quotes 24 and 25). Bloggers discussed these in conjunction with physical symptoms, including changes to their bodies that increased anxiety (i.e., hormone changes, body changes) and physiological aspects of anxiety (i.e., irregular breathing, heart palpitations, panic, and difficulty sleeping; Table 3, quote 26). Lastly, many bloggers discussed their behavioural symptoms, including withdrawing from conversations and relationships, isolating, and pulling back from previously enjoyed activities and goals (Table 3, quote 27, 28, and 29).

Researchers, practitioners, and clinicians should consider these novel findings along with their limitations. The analysis of public blogs meant that we could not determine our sample’s diversity, as blogs did not always mention sample characteristics. Contextualizing the sample is important, as prenatal people of varying socioeconomic statuses and sociodemographic backgrounds may experience prenatal anxiety differently. Furthermore, though not an objective of the current study, we were not able to follow-up with blog authors to explore their reasoning for engaging with blogs and ask clarifying questions, as bloggers’ contact information was not publicly available. Future research should explore why pregnant people engage with blogs, in addition to gathering more information about the characteristics of prenatal anxiety bloggers. There are also several limitations associated with the search strategy that we employed. We used Google to complete our search, as over 70% of Internet searches are conducted using this search engine; however, other search engines may have yielded different results [45]. Furthermore, we also only analyzed blogs that were written in English. Those written in other languages may contain different perspectives on anxiety in the prenatal period. Additionally, our search was conducted in 2017 and does not include more recent blogs that may have been posted on prenatal anxiety. An updated search may expand upon the thematic framework developed within the present study by revealing additional themes or nuances within created themes. As with all studies involving websites and blogs, online content changes rapidly; however, our objective was not to conduct an exhaustive search of all prenatal anxiety blogs, but rather, to provide a preliminary understanding of prenatal people’s experiences with anxiety as expressed through blogs, which are a relatively novel source of qualitative data within perinatal mental health research. Despite these limitations, utilizing public blogs is a novel advancement of qualitative methodology that offers access to people’s perspectives while limiting research bias.