Journal of Mental Health and Human Behaviour

: 2022  |  Volume : 27  |  Issue : 2  |  Page : 82--86

Psychosocial roots of stress during pregnancy: A cross sectional study

KV Asha 
 Department of Obstetrics & Gynaecological Nursing, Government College of Nursing, Thiruvananthapuram, Kerala, India

Correspondence Address:
Dr. K V Asha
Department of Obstetrics & Gynaecological Nursing, Government College of Nursing, Thiruvananthapuram, Kerala


Background: Pregnancy being an epoc of transition demanding heaps of remodeling and at the same time imbalance of which give rise to antenatal stress. As gestational stress is a considerable antecedent of detrimental pregnancy outcome, it is noteworthy to identify its contributing factors. The objective of the study was to determine the psychosocial factors associated with antenatal stress. Materials and Methods: Quantitative approach with a cross-sectional design was used to study the association between psychosocial factors and stress of pregnancy. Setting of the investigation was antenatal clinics of government hospitals at Thiruvananthapuram district of Kerala. The data were collected from 704 women in the gestational span of 20–24 weeks using Antenatal Psychosocial Stress Scale and structured interview schedule. Results: Bivariate analysis revealed that there is a statistically significant association between high stress and high fear of labor pain (odds ratio [OR] = 1.85, 95% confidence interval [CI]: 1.12–3.08) as well as anxiety regarding gender of baby (OR = 2.12, CI: 1.31–3.41). Conclusion: The present study revealed that heightened fear of labor pain and anxiety regarding gender of baby are the significant factors associated with antenatal stress. The study highlights the need of childbirth preparation classes attached to antenatal clinics. It also suggests the demand for abolishing gender preferences prevailing in the community.

How to cite this article:
Asha K V. Psychosocial roots of stress during pregnancy: A cross sectional study.J Mental Health Hum Behav 2022;27:82-86

How to cite this URL:
Asha K V. Psychosocial roots of stress during pregnancy: A cross sectional study. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Jun 4 ];27:82-86
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Antenatal stress has got a detrimental effect on pregnancy outcome by evoking substantial influences on the physical, psychological, and behavioral tenets of the child throughout his or her life span. Results of an investigation from the Danish National Birth cohort from 66,203 mother child pairs showed that there was more risk of mental diseases during the first 2½ years of childhood in children of mothers with high life stress in gestation. Maternal life stress throughout gestation was also connected with increased risk of disease to eye, ear, respiratory system, digestive system, skin, musculoskeletal system, and genitourinary system in children and congenital malformations in babies. Researchers concluded that reduction of life stress in gestation may be an important strategy to improve child health. There should be preventive approaches for mothers who are affected with high antenatal stress.[1] Pregnancy-specific stress is the most powerful contributor to adverse pregnancy outcomes rather than general stress.[2] Severe maternal stress affects the offspring's hypothalamo–pituitary–adrenal axis and is associated with neuropsychiatric disorders.[3]

The prevalence of antenatal distress was higher in developing countries compared with those from developed countries.[4] Accelerated changes in health, social, and structure of family in recent decades are adversely leading to a decrease in culturally established practices, which traditionally supported women during pregnancy and labor.[5] Mental health needs to be amalgamated into maternal health care in emergent nations. Considering the dearth of mental health manpower, the psychosocial health care of antenatal women should be accomplished with midwives, gynecologists, and pediatricians. In addition to the prevailing care by obstetricians, midwives and nurses can also be unitized to implement interventions which include stress reduction, exercises, and adaptation of coping skills.[6],[7]

Suggestions were raised that more research related to women's experience of labor and gestation should be conducted.[8] Investigations from many parts of the world have pointed out male child preference as a factor associated with antenatal and postnatal distress. Findings of studies have shown that the presence of multiple girl children is a significant element contributing to gestational stress. Parent counseling to minimize the fondness for male children should be an important aspect of regular antenatal care.[4],[6],[9]

Association between unwanted pregnancy or unplanned pregnancy and stress during pregnancy was investigated and similar findings were obtained from Uttar Pradesh in India, Macao in China, and North East Turkey. Observations revealed that antenatal women with unplanned pregnancy had higher levels of perceived stress.[9],[10],[11]

A qualitative approach was used to explore the perspectives of pregnant women regarding gestational stress and labor in a health center at Uganda. Causes reported were inadequate care from husbands, insensitive nurses and midwives, penury, and unplanned pregnancies. Talking to a friend, counselor, accepting one's financial situation, listening to music, and finding work to do were the coping strategies used by them.[12] On the light of available literature and based on the need for recognizing such factors associated with high antenatal stress, the present study was carried out.


The objective of the study was to identify the psychosocial factors associated with high antenatal stress among women attending the antenatal clinics of government hospitals in Thiruvananthapuram district of Kerala.

 Materials and Methods

Study design

The present study was aimed at finding out the psychosocial factors associated with high antenatal stress. Quantitative approach with a cross-sectional design was employed in the study. Exposure variables in the investigation were selected psychosocial factors of pregnancy which included pregnancy desirability, anxiety regarding gender of baby, adoption of coping strategies, and presence of high fear of labor pain. Antenatal stress was the outcome variable. Participants with high stress were categorized into a group with outcome and those up to moderate stress were grouped into another category.


The study was carried out in the selected government hospitals in the district of Thiruvananthapuram, in Kerala State, which provides prenatal and delivery care. Those hospitals are held by various levels. The broad division constitutes tertiary level and secondary level. Sree Avittom Thirunal (SAT) Hospital is categorized as tertiary level. Whereas, those marks off in secondary level are divided into hospitals in district level, taluk level, and community health centers. Single hospital from respective level was chosen randomly. CHC-Kanyakulangara, Taluk hospital-Fort, Women and children's Hospital-Thycadu, and SAT hospital were the picked centers.


Antenatal women attending the prenatal clinics associated with the government hospitals in Thiruvananthapuram district were the study population, the faction to whom the investigation results were applied. Inclusion criteria were set as prenatal women who were consenting to associate with the inquiry, who made out grasp Malayalam or English and in 20–24 weeks of pregnancy. Those who were too infirm to engage in the investigation were omitted.

Stratified sampling technique was employed to select samples from different levels of hospitals. Number of samples from each hospital was decided proportional to the antenatal coverage.

Research tool

Technique employed for data collection was interview. Antenatal stress was gauged utilizing Antenatal Psychosocial Stress Scale (APSS) which is a 10-item tool measuring stress at three levels (developed by Dr. Devisree, 2011).[13] APSS was developed and validated in the same setting. Out of the total score of 20, more than or equal to 13 (score above median + standard deviation) implies high stress. Semistructured interview schedule was used to assess psychosocial variables associated with high stress all along gestation. It consists of sections related to sociodemographic factors, obstetrical profile, and psychosocial characteristics. Review of research and nonresearch literature, discussions among experts, conversation with antenatal women and their care givers and other women who have undergone pregnancy and childbirth in the past helped in the development of research tool. Professional experience of the investigator aided in determining important items to be included in the tool. Content validity of the tools was obtained from 13 experts. Based on the opinion of experts, tools were modified. Pretesting of tools was done by administering them to 10 antenatal women. It was found that the language and content used in the tools were clear and simple. After obtaining administrative permission, a pilot study was done among 71 samples who met the inclusion and exclusion criteria. The data collected were tabulated and analyzed. It was found that the data were amenable to statistical analysis and thus the study was found to be feasible.

Ethical considerations

Approval from the institutional ethical committee and administrative permission from the hospital authorities were obtained before data collection. Written informed consent from the participants was also received. Participant information sheet with description regarding the study is handed over to all samples. Confidentiality of the data was maintained in all phases of the study.

Data collection

The data were collected during the period from September 2016 to January 2017 from women availing services from the prenatal clinics of selected hospitals. After initial screening, the investigator selected the subjects who were found to satisfy inclusion and exclusion criteria. An explanation about the objectives of the study was given; confidentiality of the data was ensured and consents were taken from the selected women. Participant information sheets were provided to them. After establishing rapport with them, the tools were administered as one-to-one basis. It took about 15 min for completing the tools.

The collected data were analyzed by carrying out descriptive and inferential statistics using SPSS, which is a statistical software suite developed by IBM for data management, advanced analytics, multivariate analysis etc. Sample characteristics were analyzed using frequencies and percentages. Association of stress and selected factors was analyzed using Chi-square test and odds ratios (ORs) were found out.


Sociodemographic characteristics of antenatal women

Sociodemographic characteristics of antenatal women are detailed in [Table 1]. Among the participants, 12.36% were between the ages of 18–20 years. Majority of (77.13%) women were in the age group of 21–30 years. A large segment of women (67.47%) reside at rural areas. Regarding religion, majority were Hindus (59.94%). About half (52.7%) of the antenatal women belong to nuclear family and a few (3.41%) belong to joint family. Among the participants, 31.11% were educated up to high school. Majority of the antenatal women (67.76%) were unemployed. Sixty-eight percentage of antenatal women belonged to BPL category. Forty-nine percentages of the women were in their first pregnancy.{Table 1}

Psychosocial characteristics of antenatal women

Psychosocial characteristics of the participants are shown in [Table 2]. A significant fraction of antenatal women (18.32%) were affected with high stress during gestation. Pregnancy was considered undesirable by 4.26% of the prenatal women. A majority of the participants (92.90%) reported about use of one or more coping strategies to relieve stress. Anxiety regarding gender of baby was a stressor for a notable fragment (14.49%) of women under study. A considerable bit of the study group (12.93%) was distressed with upraised fear of labor pain.{Table 2}

Coping strategies adopted by antenatal women

[Table 3] conveys various coping strategies adopted by the antenatal women. Prayer was the most common (55.54%) coping strategy adopted by the participants. Stress was relieved by ventilation of feelings to others by 17.76% of the sample.{Table 3}

Analysis related to psychosocial factors associated with high stress among antenatal women.

In pursuance of ascertaining association between high antenatal stress and selected variables under study, Chi-square test was carried out for which the following research hypothesis was formulated. OR was also found out. HA1: There is a significant association between high antenatal stress and selected psychosocial variables. Hypothesis was tested by Chi-sqare test at 0.05 level of significance and the findings are presented in [Table 4].{Table 4}

Pregnancy desirability is not significantly associated with high stress during pregnancy (χ2 = 1.47, P = 0.23, OR = 1.58, 95% confidence interval [CI] = 0.75–3.33). Presence of anxiety regarding gender of baby shows a significant association with high stress during pregnancy (χ2 = 9.8, P = 0.002, OR = 2.12, 95% CI = 1.31–3.41). No significant association was found between use of coping strategies and level of stress during pregnancy (χ2 = 1.44, P = 0.23, OR = 0. 59, 95% CI = 0.25–1.41). Presence of high fear of labor shows a significant association with high stress during pregnancy (χ2 = 5.84, P = 0.02, OR = 1.85, 95% CI = 1.12–3.08). Women with high fear of labor pain had 1.85 times more risk for high stress.

From [Table 4], it is clear that the computed Chi-square values are statistically significant at 0.05 level of significance for the variables such as anxiety regarding gender of baby and high fear of labor pain. Hence, research hypothesis is accepted. Hence, it is inferred that high stress is significantly associated with these variables under study. As the Chi-square values are not statistically significant at 0.05 level of significance for the variables undesirable pregnancy and coping strategies, research hypothesis is not accepted. Therefore, it can be inferred that these variables are not associated with high antenatal stress.

In order to identify the selected psychosocial factors independently associated with antenatal stress, multivariate logistic regression analysis was done. Anxiety regarding gender of baby and high fear of labor pain are independently associated with high antenatal stress. Findings of regression analysis are shown in [Table 5]. It is evident that for pregnant women affected with anxiety regarding the gender of baby, there is 2.11 times more risk for developing high antenatal stress. Similarly, those with increased fear of labor pain have 1.81 times risk for having high stress.{Table 5}


Investigation was carried out among pregnant women belonging to low-to-medium socioeconomic status who were availing antenatal services of public sector. Majority of them used coping strategies such as prayer, ventilation of feeling to others, watching TV, and reading to relieve stress. No significant association was found between use of coping strategies and level of stress during pregnancy. Another evidence related to this finding is available from Uganda, which reported that talking to a friend, counselor, accepting one's financial situation, listening to music and finding work to do were the coping strategies used by antenatal women.[12]

Presence of anxiety regarding gender of baby shows a significant association with high stress during gestation. Similar findings are available from other studies. Male child preference was identified as a risk factor for antenatal and postnatal distress.[4] Significant level of stress during pregnancy was associated with expectation of a male child by the family and worries related to giving birth to a female child.[14] Among women from Uthar Pradesh, possessing multiple girl children was a contributing factor of antenatal stress.[9]

Presence of immense fear of labor pain shows a significant association with high stress during pregnancy. A notable segment of women, (12.93%) reported substantial fear of labor pain. Women with more fear of labor pain had 1.85 times increased risk for high stress. This is in accordance with the findings from Iran, which has found out the significant association between state and trait anxiety and childbirth fear among primigravid women.[15] Another supporting report is obtained from a questionnaire survey conducted at Finland during 30th week of pregnancy which revealed that anxiety is associated with fear of vaginal delivery.[16] Poggi et al. reported that fear of childbirth (FOC) was intense for 22.45% of women at 36 weeks of gestation. Intensity of FOC symptoms was associated with intensity of pretraumatic stress symptoms.[17] In another inquiry, Hauck et al. detailed regarding the presence of elevated fear of labor for 26.1% of antenatal women.[18]

Pregnancy desirability is not significantly associated with high stress during pregnancy. Some of the previous investigations revealed that unplanned or unwanted pregnancy contributes to more stress.[9] Deposition is available from study carried out at North East Turkey, Uganda as well as from Macao, China which revealed that antenatal women with unplanned pregnancy had higher levels of perceived stress.[10],[11],[12]


Concern about the sex of the baby makes the antenatal women stressful. Dismay in the anticipation of labor pain is also a stressor. Policy level strategies for elimination of gender-based discrimination are necessary for the interception of anxiety regarding gender of baby. Child birth preparation classes should be provided in the antenatal outpatient departments focusing on building up of maternal competence and lightening the fear of labor pain. All time available helpline services for antenatal women can be recommended on the light of the study.

Some of the determinants of stress like personality traits and other psychological variables were not included in the study. Moreover, the study was limited to government hospitals. These were considered as the limitations of the study. Experimental studies for the improvement of psychological health of antenatal women can be conducted to expand the body of knowledge related to the topic. Studies on other psychological factors associated with antenatal stress can be taken up in future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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