Anxiety in pregnancy complicated by gestational and pre-gestational diabetes: a systematic review and meta-analysis

Gestational diabetes mellitus (GDM) and pregestational diabetes mellitus (pre-GDM) affect approximately 20% of pregnancies worldwide, requiring intensive management, alongside pregnancy-related concerns and broader psychosocial factors, all of which may contribute to increased psychological distress. While anxiety is associated with adverse maternal and child outcomes, evidence in women with diabetes during pregnancy remains fragmented. This systematic review and meta-analysis examined anxiety in pregnant and postpartum women with GDM and pre-GDM. This study searched MEDLINE, Scopus, Embase, EBSCO, Cochrane Library, ClinicalTrials.gov, and WHO ICTRP from inception to April 2025. Observational studies reporting anxiety outcomes in pregnant or postpartum women with GDM or pre-GDM were included. Two reviewers independently screened articles, extracted data, and assessed quality using the JBI Critical Appraisal Checklists. Random-effects meta-analyses were performed, with subgroup analyses by region and measurement instrument. Meta-regression explored heterogeneity sources. The study followed PRISMA 2020 and was prospectively registered in PROSPERO (CRD420251063824). Thirty-four studies ( n = 994,189; 38,584 GDM; 156 pre-GDM; 955,449 healthy controls) were included. Women with GDM had higher odds of antenatal anxiety than healthy controls (OR = 1.69, 95% CI: 1.20–2.37) and higher mean anxiety scores (SMD = 0.21, 95% CI: 0.07–0.34). Among eight single-arm studies reporting the prevalence of screen-positive antenatal anxiety in women with GDM, all conducted in Asia, the pooled prevalence was 36% (95% CI: 22–50%); however, this estimate should be interpreted very cautiously because of extreme heterogeneity (I 2 = 98.7%), with individual study estimates ranging from 12 to 61%. Subgroup analyses indicated stronger antenatal anxiety associations in Asian studies (SMD = 0.41, 95% CI: 0.27–0.55). Postpartum anxiety did not differ significantly between women with GDM and healthy controls (RR = 0.99, 95% CI: 0.93–1.05). Evidence regarding pre-GDM was limited and should be considered preliminary. A high burden of antenatal anxiety was observed among women with GDM, particularly in Asian populations, although precise prevalence estimates remain uncertain due to extreme heterogeneity. Postpartum anxiety appeared comparable to that of healthy women. Evidence regarding pre-GDM was based on only two studies and remains insufficient to draw conclusions. Findings suggest that targeted assessment and increased clinical vigilance may be appropriate in higher-risk subgroups; however, further prospective studies are needed before routine screening can be recommended.