Validation of the Iranian version of the Postpartum Specific Anxiety Scale 12-item research short-form for use during global crises (PSAS-IR-RSF-C)

Globally, health-related crises are the leading cause of mental disorders in all levels and age groups of society. The COVID-19 pandemic health system shock is the latest crisis with which all the countries are struggling [1]. In January 2020, the COVID-19 was declared an international public health emergency by the World Health Organization, and it did not take long for the pandemic to spread across the globe [2]. In this regard, to limit the spread of COVID-19, compliance with a series of public and social health measures, such as limiting attendance at public and private gatherings, maintaining physical distance, wearing nose and mouth masks, and quarantine, were strongly recommended by the World Health Organization [3].

Initial studies revealed poor mental health of people is associated with the various restrictions imposed by governments to slow down the spread of the virus [4, 5]. Previous studies also reveal the prevalence of mental disorders, especially among those groups thought to be vulnerable, i.e., pregnant women are significantly higher than in the general population during crises or disasters. Ignoring this can have devastating outcomes [4, 6‐9].

As one of the most significant stages of a woman's life, pregnancy and childbirth offer an opportunity for a usually happy and unique experience. However, women are exposed to mental disorders like anxiety during pregnancy and the postpartum period. Pregnancy and childbirth are stressful for women, and this health crisis will double mental disorders during pregnancy and childbirth [10].

Under normal circumstances, approximately 20% of all women who give birth are thought to experience mental health problems [11]. Though the results revealed that the prevalence of postpartum anxiety increased from 18.8% in the pre-pandemic period to 34.8% in the post-pandemic period, this issue is worth considering [12].

Wide-ranging consequences such as disruption of the maternal bond, adverse outcomes of infant feeding, reduction of mothers' self-efficacy, poor outcomes of the infant's psychological development, and infant's mood problems can be related to postpartum anxiety. These problems can impose an economic burden on the health system for both the mother and the infant [13‐15].

The importance of correct and timely identification of anxiety during the postpartum period, especially during global crises, is revealed by the extent and multiplicity of the mentioned consequences. Thus, to achieve this, it is essential first to identify this disorder [16‐18]. There are many scales to measure postpartum anxiety (PPA), including the State-Trait Anxiety Inventory (STAI) [19], and the Generalized Anxiety Disorder-7 (GAD-7) [20]. The disadvantages of these scales are their adult population oriented design, their lack of usefulness in childbearing and their limitation on reflecting the maternal-focused concerns. Consequently, to overcome these issues, the 51-item Postpartum Specific Anxiety Scale (PSAS) was developed and validated [21]. While PSAS demonstrates good psychometric properties for measure of PPA, there are increasing requests for a shorter version to aid accessibility. Therefore, a 16-question form (PSAS-RSF) was also designed [22]. Also, a 12-question form (PSAS-RSF-C) was also developed following global requests to address mental health during crises since no tool has been available to measure postpartum anxiety during global health crises, predominantly during the COVID-19 pandemic. Silverio et al. (2021) developed the Postpartum Specific Anxiety Scale – Research Short Form – for use in global Crises [PSAS-IR-RSF-C] to cope with the lack of a suitable tool to measure mothers' anxiety quickly and accurately in times of health crises. This tool included 12 questions measured on a 4-point Likert scale. This instrument consists of four domains of anxiety relating to: maternal competence and attachment, infant safety and welfare, practical infant care, and psychological adjustment to motherhood [23].

The publication presenting the development of the 12-item tool also presented unvalidated translations into Italian, French, Chinese, Spanish, and Dutch [23]. Regarding the COVID-19 pandemic and the lack of an appropriate tool to measure maternal anxiety in Iranian speaking populations, this research sets out to translate and validate the PSAS-IR-RSF-C into Persian [PSAS-IR-RSF-C].

From December 2021 to June 2022, 180 mothers were randomly included in the present study from 82 health centers in Tabriz. The participants' mean age (SD) was 27.6 (5.8) years. The majority (93.9%) were housewife. The participants’ socio-demographic characteristics are given in Table 1.

In the content validity, all items obtained the minimum acceptable value of CVI and CVR, which were 0.96 and 0.98, respectively. Face validity indicates that all items were appropriate and without vagueness and difficulty and received a minimum impact score of 1.5 (Table 2).

In the EFA process, KMO confirmed the model adequacy above 0.7 and the significant result of Bartlett's test. In the current study, Model adequacy was confirmed by KMO of 0.807 and significance of < 0.001 of the Bartlett’s test of Sphericity (Fig. 1).

According to the results of exploratory factor analysis, three factors structure was attained with a total variance of about 41.57%. The first factor includes the anxieties of practical infant care with eight questions; the second factor is the anxieties about to infant safety and welfare and includes two questions; and the third factor with two questions includes anxiety related to the marital relationship. Also, question 9 in the main scale (I felt that someone else could take care of my child better than me) was removed due to the factor load of less than 0.3 (Table 3).

In confirmatory factor analysis, × 2/df was 1.725, and the RMSEA index value was 0.063 (0.037, 0.088). These values confirmed the model's validity. TLI and CFI fitting indices were more significant than 0.9 (Table 4). As a result, this model has achieved a good level of fit, based on which it’s factorial structure can be confirmed, besides all factor-item relationships were significant (Fig. 2).

In the test–retest, the ICC (95% CI), Cronbach's alpha coefficient and McDonald’s ω were 0.97 (0.93 to 0.98),0.74 and 0.92 (0.78 to 0.93), respectively. This indicated the good internal consistency of the questionnaire (Table 3).

The COVID-19 pandemic has imposed a substantial psychological burden on society, especially on postpartum women. Based on the fact that women during the postpartum period may experience conflicting emotions due to the joy of waiting for the birth of a baby, to fear of the birth process, and various anxieties linked to parenthood [30, 31], it is no wonder that restrictions created to prevent the transmission of a global pandemic, as well as the fear of infection from the virus itself in the current health system shock, may have caused postpartum women to experience more anxiety and worries than before [4‐6]. Furthermore, identifying postpartum anxieties in the current health crisis is essential and requires a valid and reliable tool to measure postpartum anxiety.

The present study aimed to do a psychometric assessment of a specific short-form postpartum anxiety questionnaire during a global health crisis, in Iranian women. The results indicate that the Persian version of this scale is a valid and reliable tool for evaluating postpartum anxiety among Iranian women. Previously, a 51-question postpartum anxiety questionnaire was developed by Fallon et al. [21] in 2016, which has been translated into Persian after validation in an Iranian population [32]. Due to repeated requests to create a shorter form, a shortened form of 16 questions [22] was designed in 2021, which received much attention. After that, a 12-question version of this questionnaire was created to be used in times of crisis [23].

In order to determine the psychometric properties of this tool, its validity was determined using content validity, face validity, and construct validity. The reliability of the tool was checked and confirmed through internal consistency and test-retesting. Cronbach's alpha coefficient obtained for the scale was 0.74, which indicates its good internal consistency. In this regard, Silverio et al.'s study reported reliability for the whole questionnaire as 0.87 and its four factors in the range of (0.74–0.88) [23].

During the process of exploratory factor analysis, a 3-factor structure was obtained for 11 questions of the scale compared to its original version, which had four factors and 12 questions. Furthermore, the explained variance of the factors for measuring the desired concept in the questionnaire was about 42% (3 factors) for the 3-factor structure, which was equal to 0.75% (4 factors) in the original questionnaire [19]. Also, the value of KMO and the significance of Bartlett's test, and the value of RMSEA, 0.064, confirmed the model adequacy.

The first factor obtained during exploratory factor analysis is the anxieties about the practical infant care, which includes eight items. The second factor expresses the anxieties of infant nutrition and growth, which includes two items; the third factor concerns the anxieties caused by marital relationships, which includes two items.

Based on the results of the studies, part of the anxiety women suffer in the postpartum period is caused by anxiety related to the health and practical care of the baby. In this regard, via a structured interview, Affonso et al. investigated the effects of postpartum anxiety on 84 primiparous women and 137 multiparous women six weeks after childbirth. The most common reported theme for both groups in this study was concern about health and infant care [33].

Feeding behaviors and infant growth are other essential issues of postpartum anxiety. Generally, the first three months after delivery is a critical period for infants. The mother's mental state affects the infant's feeding behaviors during this period [34]. In this regard, a prospective cohort study disclosed that postpartum anxiety increases breastfeeding cessation in fewer than six weeks by 157% and breastfeeding for fewer than eight months by 124% [35]. Sun et al. (2020) indicated that maternal anxiety during postpartum was associated with harmful infant feeding practices, such as bottle feeding and refusal to feed the infant [36].

Consequently, the mother's mental health may be an essential factor in the nutrition and development of the child. Because negative emotions and anxiety during the feeding of the child may affect the function of the mother's cerebral cortex, hypothalamus, and pituitary gland, reduce the secretion of prolactin and oxytocin and finally reduce the breast milk secretion [34, 37].

Fallon et al. (2016) showed that women who have symptoms of postpartum anxiety are less likely to have exclusive breastfeeding, and it is more likely that they stop breastfeeding early and use formula [16]. Fallon et al., (2018), in another study using the PSAS, identified that higher levels of postpartum anxiety are associated with a lower likelihood of exclusive breastfeeding and breastfeeding at any rate in the first six months postpartum. PSAS scores were significantly associated with infant feeding behaviors. As a result, compared to the general anxiety and depression tools, the PSAS tool was a stronger predictor of infant feeding outcomes and behaviors [38].

Marital relation is another factor which is discussed in most studies. Though pregnancy is a physiological process, the physical changes that occur may increase the need for support felt by women [39]. Odinka et al. (2018) showed that women with postpartum anxiety and depression were 22% less satisfied with their married life [40]. Another longitudinal study on the relationship between marital life quality and postpartum depression and anxiety during the third trimester of pregnancy and four to six months after delivery showed that variables of marital relationship and marital satisfaction, postpartum depression levels and marital satisfaction significantly predicted postpartum anxiety levels. As a result, the quality of marital relationships should attract physicians' attention in the perinatal period. Providing psychological interventions to improve the performance of marital relationships may help prevent psychological distress in mothers [41].

Considering the crisis, we are currently facing and the unfortunate consequences of postpartum anxiety that has been neglected, and since there is no specific tool for measuring postpartum anxiety in crises, the importance of having a specific tool to measure postpartum anxiety increases in critical times.

Since the recent global health crisis has severely affected the mental health of pregnant women. In postpartum period, women will experience many problems in the field of mental health, which makes it necessary to have a short and specific tool for this period. Considering that this tool is valid and reliable for assessing postpartum anxiety for global crisis in Iranian postpartum women, health care providers can use it to evaluate the state of mental health in the postpartum period.