TLDR; Summary

The PASS is a self-report measure used to screen for and assess the severity of anxiety symptoms in expecting and new mothers during the perinatal period. It consists of 31 questions asking a client to indicate the frequency of various anxiety-related symptoms surrounding their pregnancy and baby over the past month. Total scores are calculated via the summation of each item. Potential total scores range from 0 to 93 with high scores indicating higher levels of perinatal anxiety.

Limitations for the PASS include an inability to diagnose any specific disorder and its variations for cut-off scores in different cultures and translations. As of the creation of this explainer, there is no research on the efficacy of the PASS in gender-diverse expecting parents. Even with these limitations, the PASS may be useful for the screening of perinatal anxiety and tracking client progress with perinatal anxiety when using a continuous scoring approach.

Highlights

📏 Lengths: 31 items with an average completion time of six minutes

📋 Administration: Self-administered

🎯 Uses: To screen and assess anxiety symptoms in women during the perinatal period.

⚠️ Important Caveats: All current research on the efficacy of the PASS appears to be in samples of cisgender women, so its usefulness with non-binary/otherwise gender diverse pregnant AFAB (assigned female at birth) people is unknown.

✅ Available in Bravely Connect? Yes

🌏 Culturally Applicable? Small amount of research suggests yes, but the thresholds for problematic anxiety levels may vary based on translation.

The PASS Question type and length

The client is presented with 31 questions asking clients to indicate the frequency of various anxiety-related symptoms surrounding their pregnancy and baby over the past month. Each item has the same selection of answers: a 4-point Likert scale ranging from 0 (not at all) to 3 (almost always). A higher score indicates higher levels of pregnancy- and baby-related anxiety

Here is an example of an item from the PASS and the range of answers:

Over the past month, how often have you experienced the following?

Worry about the baby/pregnancy

• Not at all (0 points)

• Sometimes (1 point)

• Often (2 points)

• Almost always (3 points)

A sense of dread that something bad is going to happen

• Not at all (0 points)

• Sometimes (1 point)

• Often (2 points)

• Almost always (3 points)

For the full list of questions check out the measures on Bravely Connect.

What does the PASS measure?

The Perinatal Anxiety Screening Scale (PASS) is a self-report measure designed to screen and assess anxiety symptoms in new mothers during the perinatal period (during pregnancy and shortly after). The measure consists of 31 items assessing symptoms from a variety of anxiety-related disorders including generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, social anxiety, PTSD, adjustment disorder, and phobias (Somerville et al., 2014). Several items specifically relate to the baby and pregnancy while the rest assess anxiety more broadly. Potential scores range from 0 to 93. Higher scores indicate higher levels of perinatal anxiety.

PASS Factor structure

The PASS authors created the measure intending to assess a broad variety of anxiety disorder-related symptoms in expecting and new mothers, giving special consideration to the ways anxiety often manifests during the perinatal period. The initial study developing and validating the PASS found four factors: 1) acute anxiety and adjustment, 2) general worry and specific fears, 3) perfectionism, control, and trauma, and 4) social anxiety (Somerville et al., 2014).

The “acute anxiety and adjustment” factor contained eight items related primarily to panic disorder, dissociative disorder, and adjustment difficulties. The “general worry and specific fears” factor encompasses ten items related to generalised anxiety disorder symptoms and phobias. The third “perfectionism, control, and trauma” factor contained eight items relating to obsessive compulsive disorder and PTSD. The final “social anxiety” factor had five items assessing social anxiety disorder symptoms. Some translations of the PASS find a similar four factor structure, but with slightly different distributions of the items between the different factors (Coo et al., 2021; Koukopoulos et al., 2021; Yazıcı et al., 2018).

The history and theory behind the PASS

The PASS was created in 2014 by a group of five perinatal psychologists from the Department of Psychological Medicine at King Edward Memorial Hospital in Australia. The PASS is based on several pre-existing measures for anxiety-related conditions as many pregnant women with anxiety presented with a constellation of anxiety symptoms, especially focused on motherhood (Somerville et al., 2014). At the time of the PASS’ creation, the contemporary measures such as the Postpartum Worry Scale and the Postpartum Specific Anxiety Scale fell short in how they were not validated for the entire perinatal period, instead focusing solely on the postpartum period (Koukopoulos et al., 2021). Other measures assessing generalised anxiety were flawed in how they assessed physical symptoms which often overlapped with physical sensations common in pregnancy, thus artificially inflating scores (Somerville et al., 2014).

The authors of the PASS sought to create a new measure that would accurately assess anxiety symptoms as they manifested in expecting and new mothers throughout the entire perinatal period. Using the DSM and ICD-10 diagnostic criteria for anxiety-related conditions, the authors devised a 38-item questionnaire addressing symptoms of GAD, panic disorder, OCD, social anxiety, PTSD, adjustment disorder, phobias, and trauma-related dissociation. The measure was validated in a sample of 393 women. Seven reverse-scored items were removed from the final iteration of the PASS resulting in the 31-item measure used today. 

PASS Scoring Interpretation

Scoring for the PASS is calculated via the summation of item scores. PASS is scored using a 4-point Likert scale ranging from 0 (not at all) to 3 (almost always). Potential scores range from 0 to 93 with higher scores indicating higher levels of perinatal anxiety. For a dichotomous scoring method, a cut-off score of 26 indicates a high likelihood of perinatal anxiety (Somerville et al., 2014). A cut-off score of 26 identifies 68% of women at high risk of an anxiety disorder (Somerville et al., 2015). However, some research validating translations of the PASS find different cut-off scores to be more appropriate.

For the purposes of assessing and tracking changes in the levels of a client’s perinatal anxiety, the PASS may also be scored on a continuum with scores between 0 and 21 suggesting minimal anxiety, scores between 22 and 41 suggesting mild-to-moderate anxiety, and scores from 42 to 93 suggesting severe anxiety (Somerville et al., 2015).

Who developed the PASS measure?

The PASS was developed in 2014 by a team of specialist perinatal psychologists in the Department of Psychological Medicine at King Edward Memorial Hospital (Somerville et al., 2014) in collaboration with the Western Australian Department of Health. They created the PASS in response to the growing body of research finding that maternal anxiety before and after childbirth has negative effects on both new mothers and their babies. The PASS aims to identify potential cases of perinatal anxiety so it may be adequately treated.

The PASS is available on Bravely Connect as part of our automated measures. 

• Find out how you can use the PASS on Bravely Connect →

  
  

Limitations, biases and when you should/shouldn’t use the PASS

The PASS is a self-report measure that assesses respondents’ levels of anxiety surrounding their pregnancy and newborn. While the PASS is able to identify potential clinically-significant levels of anxiety and is based on diagnostic criteria, it is to be used as a screening tool, not a diagnostic tool.

In terms of cross-cultural applicability, the PASS has been evaluated and validated in several different languages and cultures, including in samples outside of its originating Western context. Some translations have found differences in effective cut-off scores for identifying potential clinically-significant cases of perinatal anxiety. Cross-cultural validation studies of the PASS include the following:

• A sample of 206 Iranian perinatal women using a Persian translation (Barzgar-Molan et al., 2020)

• A sample of 217 antenatal and postnatal women in eastern Saudi Arabia using an Arabic translation (Jradi et al., 2020)

• A sample of 312 perinatal women in Turkey using a Turkish translation in which a cut-off point of 16 was identified, possibly due to culturally-influenced inclinations to keep anxiety to oneself leading to a lower self-admitted score indicating high anxiety levels (Yazıcı et al., 2018)

• A sample of 151 perinatal women in Bangladesh using a Bangla translation (Farjana & Islam, 2018)

• A sample of 289 perinatal Italian women using an Italian translation (Koukopoulos et al., 2021)

• A sample of 221 perinatal women in Sri Lanka using a Sinhala translation in which a cut-off of 20 was identified, suggesting a similar cultural phenomenon to that seen in the Turkish validation study (Priyadarshanie et al., 2020)

• A sample of 265 Chilean women—138 during the third trimester of pregnancy, 127 at three months post-partum—using a Spanish translation (Coo et al., 2021)

As of February 2024, there appears to be no research on the efficacy of the PASS in gender diverse pregnant people. All current research utilises cisgender terminology, and the language in this explainer mirrors the language used in the research we are referencing. We recognise the possibility of pregnancy in FTM transgender men, non-binary people, and otherwise gender diverse people assigned female at birth. 

As with many measures developed and validated in Western cultures, we recommend that the PASS be used in conjunction with comprehensive clinical assessments taking a client’s unique sociocultural background into consideration.

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Full reference list available on request.