Compared to pregnant women from Guangzhou, those from Tibet have a higher prevalence of both anxiety and depression. Previous studies indicated that the prevalence of anxiety and depression among pregnant women in Guangzhou was the same as the average level in China. In our study, the incidence of anxiety among pregnant women from Guangzhou was 19.1%, and was consistent with previous studies in China(17). The prevalence of depression was 30.2%, while 10.1% of all was moderate depression, which was similar to the results of some studies completed in other provinces of China(17, 18). However, the incidence of anxiety and depression among Tibetan pregnant women was 42.6% and 69.2%, respectively, which was much higher than the previous studies and higher than the rest of China.
According to previous studies, the factors affecting anxiety and depression among pregnant women included age, educational experience, family income, employment situation, trimester and history of abnormal pregnancies(17, 18). We noticed that trimester was the main factor contributing to anxiety among pregnant women in Guangzhou. Women in the early stages of their pregnancy had a higher SAS score. This may be related to the changes in female hormone levels in early pregnancy, the influence of their response to an early pregnancy and the lack of knowledge on pregnancy care. What’s more, the first trimester of pregnancy is the key period of fetal development, the fear of miscarriage and fetal deformities can also make them greater anxious(19).
Consistent with the results of previous study(18), delivery times is also the main factor contributing to depression among pregnant women in Guangzhou, China. Women, especially older women, that have delivered more than twice are more prone to experiencing depression during pregnancy. In our study, 67.4% of pregnant women were older than 30 years of age, including 39.6% of them were elderly pregnant women, and 20.8% of them had pregnancy complications. Pregnancy complications can increase the incidence of anxiety and depression in pregnant women. However, with the gradual opening of the second child policy in China, there will, in the future, be more elderly pregnant women. The mental health for this group of people should be paid more attention. Besides, among those pregnant women from Guangzhou, SAS and SDS scores of Han nationality were higher than those of other nationalities. However, mainland China is mainly inhabited by Han nationality and the proportion of other nationalities is very small, so we think this result is not representative.
In our study, we found that the educational experience was the main factor affecting anxiety and depression of pregnant women in Tibet. Pregnant women with a low level of education had higher SAS and SDS scores. This result is consistent with previous studies(18). Tibet is located on the Qinghai-Tibet plateau in southwest China and it has an average altitude of over 4000 meters(14). The cold and oxygen-deficient environment makes Tibet relatively backward developed among China, both economically and educationally. In our study, 26.6% of pregnant women in Tibet have only a primary school education or less. They would usually lack awareness, and their expression, understanding and acceptance ability were often lower than those with higher educational level. Therefore, most of them have limited awareness about regular prenatal examinations and the average times of their examinations were usually only one to two times. Most of the women in Tibet were unable to provide an accurate time of their last menstrual period, making it difficult to calculate their gestation week and proceed the subsequent scheduling prenatal examinations.
Due to the limited medical facilities and environment, the propaganda of pregnancy health care knowledge in Tibet is very inadequate. The unique language and writing in Tibet restrains pregnant women from accessing enough information from the outside world, such as the Internet and books. The whole process of pregnancy lasted about 40 weeks and all the daily diet, rest, exercise, drug use and mental health care during pregnancy need professional advice. When those pregnant women in Tibet are faced with some physiological changes or pregnancy complications, their lack of relevant knowledge and external help may end up with feeling anxious and increasing mental stress, even result in anxiety, depression and other perinatal mood disorders, which can severely damage both maternal and infant’s health.
To sum up, pregnant women in Tibet had higher SAS and SDS scores than Guangzhou, indicating the higher incidence rate of anxiety and depression. In future work, more attention should be paid to pregnant women in Tibet, especially those with low levels of education(17). To alleviate the problem of perinatal anxiety and depression, many attempts have been made in China and other countries. Based on previous studies, usage of anti-anxiety and anti-depression drugs would increase the incidence of eclampsia, even leading to neonatal toxicity, and fetal growth disorders(20, 21), which limit the use of these drugs. Other psychological interventions would be safer and more acceptable, such as hypnosis, cognitive behavioral therapy, music therapy, yoga and so on(22–26). However, compared with Guangzhou, the limitation of medical facilities and environment in Tibet restrain the generalization of the above therapies. It is very urgent to establish and strengthen the three-level maternal and child health care network in Tibet(7).
For the future, we hope to reduce perinatal anxiety and depression in Tibet by establishing an online education platform between local hospitals and other top hospitals in China(27). This platform will provide systematically training to local doctors and nurses through information sharing on health care of pregnant women. It will also provide professional psychological guidance for pregnant women by using online schools. Simultaneously, to meet the needs of pregnant women from different nationalities, our courses for physiology and mental health care will be available in both Mandarin and Tibetan languages. This will significantly reduce perinatal anxiety and depression in Tibet by improving their ability for self-caring. As the platform matures, the remote maternal health care courses would be expanded to more counties and villages and available by further more people and communities.