Validity and accuracy of the Whooley
questions to identify maternal distress in
Dutch pregnant women
Yvonne Fontein-Kuipers and Julie Jomeen
Purpose –The purpose of this paper is to investigate the validity and accuracy of the Whooley questions for
routine screening of maternal distress in Dutch antenatal care.
Design/methodology/approach –In this cohort design, the authors evaluated self-reported responses to
the Whooley questions against the Edinburgh Depression Scale screening for antenatal depression,
State-Trait Anxiety Inventory for general anxiety and the pregnancy-related anxiety questionnaire-revised
screening for pregnancy-related anxiety, among Dutch pregnant women during the first and third trimester of
pregnancy. The authors used standard diagnostic performance measures for the two case-finding items.
Findings –The Whooley itemsin this study showed a higher specificitythan sensitivity. The Whooley results
showed goodevidence to identify women who are depressedor (trait)anxious in both trimestersof pregnancy,
but the results showedweak to moderate evidence to identify pregnancy-related anxiety. The Whooley items
had a low to moderatepredictive ability for depression, trait-anxietyand pregnancy-related anxietyand a good
ability for negative case-finding. The Whooley items proved to be more able to report how effective the
case-findingquestions are inidentifying women withoutdepression, trait-anxietyand pregnancy-relatedanxiety
(ruling out) rather than how effective these are in identifying women with depression, trait-anxiety and
pregnancy-related anxiety (ruling in). The Whooley items were accurate in identifying depression and
trait-anxiety in bothtrimesters but were not very accurate to identify pregnancy-relatedanxiety.
Research limitations/implications –Assessment of pregnancy-related anxiety using a case-finding tool
requires further attention.
Practical implications –The two-item Whooley case-finding tool has shown good utility as a screening
instrument for maternal distress. The continuous assessment of maternal emotional health during the
childbearing period or, at least, revisiting the topic, would both support the woman and the midwife in
regarding perinatal emotional wellbeing as an important remit of midwifery care.
Originality/value –A novel aspect of this paper is the proposition of applying the Whooley questions at later
stages of pregnancy or presenting the Whooley questions in a written or digital form.
Keywords Antenatal anxiety, Antenatal depression, Case-finding, Maternal distress,
Pregnancy-related anxiety, Whooley
Paper type Research paper
Maternal distress refers to a spectrum of psychological symptoms during the antenatal period.
Depression, stress and anxiety, either pregnancy or non-pregnancy/ birth related, are the most
commonly mentioned constructs of maternal distress. There is increasing evidence that maternal
distress among otherwise healthy pregnant women can be a predictor for preterm labour and
low birth weight. Additionally, adverse short- and long-term postpartum mental health effects
have been reported for both mother and child, including postpartum depression and
post-traumatic stress (Mulder et al., 2002; O’Connor et al., 2002; Heron et al., 2004; Son van
et al., 2005; Leigh and Milgrom, 2008; Loomans et al., 2013; Blackmore et al., 2016), behaviour
and emotional problems in children, and problematic family relationships (Mennes et al., 2006;
Robinson et al., 2008; Goodyer and Cooper, 2011; Glover, 2013). The population prevalence of
Received 4 June 2018
Revised 15 August 2018
Accepted 15 November 2018
Disclosure of interest: there are no
conflicts of interest to declare. The
authors would like to thank the
Regional Attention and Action for
Knowledge research project
funding (RAAK PRO, ref. 2-014)
and the project group “Promoting
Healthy Pregnancy”of the Zuyd
University of Applied Sciences.
Yvonne Fontein-Kuipers is
based at the School of Midwifery
and Research Centre
Innovations in Care, Rotterdam
University of Applied Sciences,
Rotterdam, The Netherlands;
Faculty of Medicine and Health
Sciences, Antwerp University,
Antwerp, Belgium; and Faculty
of Health sciences, University of
Hull, Hull, UK.
Julie Jomeen is based at the
Faculty of Health Sciences,
University of Hull, Hull, UK.
DOI 10.1108/JMHTEP-06-2018-0034 VOL. 14 NO. 1 2019, pp.33-45, © Emerald Publishing Limited, ISSN 1755-6228
THE JOURNAL OF MENTALHEALTH TRAINING, EDUCATION AND PRACTICE