4. Discussion
generalised, lower depression, anxiety, depressive, depressive symptoms, depression
RECRUITMENT, BLIND
Although it has been well documented that first-trimester PE screening is of clinical value [The study findings revealed that, among the various psychological distress outcomes considered, women identified to be at high risk for PE during the first-trimester screening exhibited more depressive symptoms at 22 weeks of pregnancy compared to low-risk women. These symptoms were transient as no significant differences between the low-risk- and high-risk-for-PE groups were identified in the third trimester. No differences between the two groups in anxiety, mental health, or worry about own or baby’s health were identified at any point of assessment. There were differences in the physical health in the first and third trimesters between the two groups of women, but these could be seen as cohort effects rather than “true” differences as such differences were present at baseline, before the PE screening test result was known. Our findings showcasing no elevations in anxiety levels are aligned with the findings of Simeone and colleagues, who reported that there is no adverse impact of the “high-risk” PE status on women’s anxiety levels [Our study identified that the high-risk-for-PE group reported to have made more changes to their health behaviours compared to women at low risk for PE. The questions relating to health behaviours mostly focused on dietary changes (eating more healthily; consuming less salt and fat and more fibre). It is important to note that medical professionals did not explicitly recommend changes to health behaviours to women at high risk for PE during antenatal screening. In line with suggestions that pregnancy can offer “teachable moments” for health behaviour change [We hypothesized that engagement in health behaviour change would be moderated by women’s depression levels. This hypothesis was supported as, amongst high-risk women, those reporting higher depression scores were significantly less likely to report having made changes to health behaviours in the second and third trimester in comparison to women with lower depression scores. Thus, although a high-risk test result may trigger changes in health behaviours, this could be hindered by the depressive symptoms experienced by the woman. This is an important finding as it suggests that depressive states may reduce the sense of agency and behavioural control that women will display during pregnancy, and that affected women will be less likely to engage in changes in health behaviours that would support their own health and that of their unborn child. This finding is concordant with a recent study [We found that the majority of women, regardless of their PE risk status, reported having had a positive experience of pregnancy and most of them endorsed the benefits of screening as outweighing the perceived costs. The majority also stated they were likely to request PE screening in a future pregnancy and recommend it to pregnant friends and relatives. Others have also reported that, generally, pregnant women, as well as those at high risk for PE, hold positive views in relation to PE screening in pregnancy [Our study findings offer unique insights not only towards a better understanding of the psychological impact of first-trimester PE screening on pregnant women, but also offer supportive evidence concerning the appropriateness of such a screening in ethical terms. From an ethical standpoint, the benefits of introducing novel screening programmes should be weighed against the potential harm for those women falsely screened as positive [Our findings need to be considered in light of the study limitations. Despite the considerable sample size overall, attrition in the study was significant and led to small sample sizes, particularly in the high-risk group during the last evaluation phase. The low incidence of the high-risk-for-PE status and the adopted longitudinal study design offered further challenges to the recruitment of the high-risk-for-PE cohort. Due to the loss of participants over time and the variability in participants at each time point of assessment, we were unable to treat our data as “truly” longitudinal and our data analytic strategy was adjusted to address that shortcoming in the main data set. We then also analysed the smaller subsample of the high-risk women who met the criteria of the prospective longitudinal design and were able to identify a very similar set of findings. Issues relating to recruitment and attrition will remain a challenge for researchers examining the impact of PE screening. The strength of our study is that a large number of confounders were included in the analyses, which gives confidence to the validity of our findings. Our study sample was predominantly White and well educated, and it is not possible to know to what extent our findings can be generalised to more ethnically, socially, and economically diverse populations. In addition, our study was nested within the ASPRE trial, an RCT for the prevention of PE using low-dose aspirin vs. a placebo. The women in our study were “blind” to whether they were taking aspirin or a placebo, but all of the high-risk women were offered additional monitoring and scans throughout pregnancy, which they found reassuring and beneficial [