Anxiety in Obstetrics: Seeing What We’ve Been Missing

Screening for anxiety should be as routine as measuring blood pressure in pregnancy and postpartum care.

Anxiety remains one of the most underrecognized complications in obstetrics. It interferes with recovery, bonding, sleep, and lactation, yet it often hides behind physical complaints or is dismissed as normal adjustment. Structured assessment allows early identification and treatment, particularly during the vulnerable postpartum year. Two validated tools—the Generalized Anxiety Disorder 7-item scale (GAD-7) and the State–Trait Anxiety Inventory (STAI)—are practical, evidence-based instruments every obstetric clinician should know how to use.

The Generalized Anxiety Disorder 7-item scale (GAD-7)

Purpose:
To screen for and rate the severity of generalized anxiety disorder symptoms over the past two weeks.

Instructions:
Ask each question as written:
“Over the last two weeks, how often have you been bothered by the following problems?”

Items:

1. Feeling nervous, anxious, or on edge.

2. Not being able to stop or control worrying.

3. Worrying too much about different things.

4. Trouble relaxing.

5. Being so restless that it is hard to sit still.

6. Becoming easily annoyed or irritable.

7. Feeling afraid, as if something awful might happen.

Response options:
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day

Scoring and interpretation:
Add all responses (range 0–21).

• 0–4 = Minimal anxiety

• 5–9 = Mild anxiety

• 10–14 = Moderate anxiety

• 15–21 = Severe anxiety

A total score of 10 or higher indicates clinically significant anxiety and should prompt further evaluation, follow-up, or treatment. The GAD-7 is short enough to be completed in two minutes and can be incorporated into postpartum visits, telehealth check-ins, or nurse outreach assessments.

The State–Trait Anxiety Inventory (STAI)

Purpose:
To measure both temporary (state) anxiety and long-term (trait) anxiety, distinguishing situational distress from a chronic predisposition.

Structure:
40 self-report statements divided into two sections of 20 items each:

• State Anxiety (S-Anxiety): how the patient feels right now, at this moment.

• Trait Anxiety (T-Anxiety): how the patient generally feels in daily life.

Response options for both sections:
1 = Not at all (for State) / Almost never (for Trait)
2 = Somewhat / Sometimes
3 = Moderately so / Often
4 = Very much so / Almost always

State Anxiety items (examples):

1. I feel calm.

2. I feel secure.

3. I am tense.

4. I feel strained.

5. I feel at ease.

6. I feel upset.

7. I am presently worrying over possible misfortunes.

8. I feel satisfied.

9. I feel frightened.

10. I feel comfortable.

11. I feel self-confident.

12. I feel nervous.

13. I am jittery.

14. I feel indecisive.

15. I am relaxed.

16. I feel content.

17. I am worried.

18. I feel confused.

19. I feel steady.

20. I feel pleasant.

Trait Anxiety items (examples):

1. I feel pleasant.

2. I feel nervous and restless.

3. I feel satisfied with myself.

4. I wish I could be as happy as others seem to be.

5. I feel like a failure.

6. I feel rested.

7. I am calm, cool, and collected.

8. I feel that difficulties are piling up so that I cannot overcome them.

9. I worry too much over something that really doesn’t matter.

10. I am happy.

11. I take disappointments so keenly that I can’t put them out of my mind.

12. I am a steady person.

13. I get in a state of tension or turmoil as I think over my concerns and interests.
    (20 total statements scored the same way.)

Scoring and interpretation:
Each subscale produces a total score between 20 and 80.
Higher scores indicate greater anxiety.
Scores above 40–45 are usually considered clinically significant, although specific cutoffs vary by population and purpose.

Use in obstetrics:

• State anxiety reflects immediate stress (for example, around labor, hospitalization, or neonatal complications).

• Trait anxiety captures long-term vulnerability, predicting who may experience recurrent anxiety or postpartum mood disorders.

Clinical Integration and Reflection

The GAD-7 is ideal for routine screening—a rapid triage tool for office or postpartum nurse visits. The STAI offers depth and differentiation, useful for high-risk pregnancies, NICU mothers, or research settings. Using both instruments gives obstetricians a clear map of maternal anxiety across time: the GAD-7 quantifies symptom intensity, and the STAI clarifies its origin and persistence.

Anxiety is not an invisible emotion but a measurable clinical signal. Incorporating structured screening into obstetric care transforms vague reassurance into targeted prevention. When we ask the right questions, we give anxiety the clinical weight it deserves—equal to blood pressure, hemoglobin, or fetal growth. In doing so, we protect not only maternal mental health but the foundation of postpartum recovery itself.