Anxiety of mothers of newborns with congenital malformations in the pre- and postnatal periods

ABSTRACT Objective: to analyze the anxiety level of the mothers of newborns with congenital malformations who were diagnosed in prenatal and postnatal care. Methods: a cross-sectional study with 115 mothers of 117 newborns with congenital malformation admitted to three neonatal units. A questionnaire containing maternal and neonatal variables was used, as well as the Trait-State Anxiety Inventory. Data were analyzed by Student’s t-test and Kolmogorov-Sminorv test. The anxiety level was categorized as low (percentile <25), moderate (25-75) and high (> 75), with a significance level of 5%. Results: most mothers had moderate levels of anxiety. Regarding the diagnosis of the malformation, 57% received the news in the prenatal and 43% in the postnatal period. The anxiety level of those who received the prenatal diagnosis was lower than those who received in the postnatal period, evaluated by the Trait Anxiety Inventory (p = 0.026). Conclusion: mothers of newborns with malformations presented moderate anxiety, and this was higher when the diagnosis was given in the postnatal period. The use of the Trait-State Anxiety Inventory can provide guidance to other studies and to clinical practice.

gestational period are quite prevalent and common, and multiple risk factors are involved in their genesis.
However, they are still underdiagnosed (9) . During the postpartum period, researchers report that 11% of mothers of healthy newborn develop symptoms of depression within 72 hours after birth (10) and that after six weeks they also presented symptoms of traumatic stress and/or anxiety (11) . In the postpartum period, there is an increased risk of suffering, especially among mothers of newborns with confirmed malformations, who will stay hospitalized after birth. Therefore, the early identification of psychological distress in this period and the referral to mental health care providers within the obstetric environment are essential (12) .
As an ally in the evaluation of anxiety and the behavior of pregnant women after receiving the diagnosis of congenital malformation, a study carried out in a hospital environment used tools, more specifically scales, that were appropriately validated and multidimensional, adapted to the Brazilian population, in an attempt to understand the coping strategies, as well as the thoughts and actions adopted in the face of a particularly stressful event (13) .
There has been scarcity of studies that evaluate the impact of the news of congenital malformation in the different periods of gestation (1) , and this encouraged the development of the present study, which shows to be relevant due to its great value in investigating the anxiety level experienced by the mothers during this transition phase of their lives. Thus, based on the results, health professionals, especially nurses, can encourage health promotion actions according to women's needs, contributing to the strengthening of emotions, demystifying fantasies, creating bonds and fortifying the relationship between family and the newborn.
Nursing, as a profession, like the other health areas, uses technologies to implement assistance to its clients and to promote autonomy and independence, whether in closed institutions, such as hospitals, for health education or in any other environment (14) .
In this context, the research questions are: What is the anxiety level of the mothers of newborns with malformations hospitalized in the Neonatal Unit of hospital institutions, according to the Trait-State Anxiety Inventory (STAI)? Is there a difference in maternal anxiety levels when the malformed child is diagnosed?
Thus, the objective was to analyze the anxiety level of the mothers of newborns with congenital malformations who received the diagnosis in the prenatal or postnatal period.

Method
This was a quantitative, cross-sectional and comparative study carried out in three tertiary-level hospitals in Fortaleza-CE, in a neonatal admission unit and rooming-in, a reference in neonatal care to the rural Fontoura FC, Cardoso MVLML, Rodrigues SE, Almeida PC, Carvalho LB. and urban population of the state. The study population was composed of puerperal women whose children had congenital malformations diagnosed during the prenatal or postnatal period and were hospitalized at the neonatal unit during the period of data collection. The sample was selected by convenience, in which the neonates were initially captured in the neonatal units and, later, the mothers were located to apply the research eligibility The data were collected by the researcher during the daytime period, as it was the moment when the family was more available and were visiting the newborn in the units, which favored making the invitation for participation. The instruments were applied in the first week after birth (up to 7 days), this period being the most favorable period for this collection because the newborn was still hospitalized in the neonatal unit (15) .
Daily telephone contacts were made with the nurses of the units surveyed, as well as periodic visits to the institutions for finding these newborns and their mothers. Subsequently, the instruments used in the study were applied: a questionnaire containing sociodemographic, maternal and neonatal variables; and the Trait-State Anxiety Inventory (STAI).
The STAI is a self-assessment questionnaire for adults (16)

Results
Among the 115 mothers studied, 50% were aged between 19 and 29 years, 47% were from Fortaleza, 50% lived in stable union with their partners, 52% had studied for 6 to 10 years, 93% declared to be browns, 41% were primigravida, 83% had undergone cesarean delivery and 4% had used licit and/or illicit drugs during gestation. There was variation regarding anxiety, as detected by the STAI, according to Table 1.  Before analyzing the means of the scales, we performed the Kolmogorov-Smirnov test, which indicated that they did not present normality: STAI-Trait (p <0.0001) and STAI-State (p = 0.001). Despite this, the Student's t-test was used for this analysis, since the sample size was large enough (n = 115) to do so, according to the Central Limit Theorem (19) .
Only the means of the STAI-Trace showed statistically

Discussion
In general, the results showed that the mothers of malformed newborns presented different anxiety levels during the pre-and postnatal periods. For parents, the news of a diagnosis of congenital anomaly in their child can trigger many reactions, which may vary according to, for example, the moment the diagnosis is revealed (20) .
Some studies state that admission to and severe anxiety (23) .

4.5% of mothers of normal babies had indicative scores
for both depression and anxiety symptoms (15) .
The fact that the mother is primiparous is also a strong indicator of association with anxiety, as shown in another Brazilian study that analyzed anxiety and maternal coping in the presence of a congenital anomaly, which identified association between maternal variables and emotional indicators. The results showed a strong association between the mother being primiparous and the minimum level of anxiety (p = 0.019), as well as the majority of the mothers received the news of the diagnosis of malformation before birth (24) . anxiety in the first visit presented the highest mean score, since they did not know whether the child would be diagnosed with anomalies (25) .
Anxiety is usually associated with other types of mental changes and/or feelings. Research conducted in Iran described anxiety and depression as associated disorders that were investigated in mothers during the postnatal period who had high-risk pregnancies. The prevalence of symptoms of depression and moderate anxiety was higher among women who had a highrisk pregnancy than those with normal pregnancies.
However, anxiety was more prevalent than depression in both groups (26) . significance for the feeling of anger, being more intense (p = 0.004), and for sadness (p = 0.044), than mothers who had received the diagnosis of congenital malformation after birth (27) .
A study that evaluated individual adjustment This research had some limitations, such as not following these mothers after hospital discharge, since the anxiety experienced at that time could decrease or increase over time due to possible morbidities caused by the malformation of the child or even deaths, in more severe cases or incompatible with life. In addition, we also had difficulty in finding the complete records of the diagnoses of the newborns. Due to the fact that the malformations are not of compulsory notification, in certain medical records it was not possible to obtain the complete information, so we need to seek help from professionals working in the sector for clarification.
As a suggestion for other studies, we suggest longitudinal follow-up of these mothers in order to contribute to a better adaptation to the experienced situation, as a way to minimize or prevent other mental disorders common to this population.

Conclusion
The application of the STAI revealed that the mothers of newborns with malformations presented moderate anxiety. The news of the malformation of the child, received by the mothers in the postnatal period, triggered higher levels of anxiety than those who received it in the prenatal period, but this difference occurred only in the evaluation through the STAI-Trait scale. The use of technologies, such as the STAI, can provide guidelines for other studies and clinical practice.