Objective This study aimed to determine the prevalence and associated factors of perceived stress among pregnant women during the COVID-19 pandemic period in Northwest Ethiopia.
Method A cross-sectional study.
Setting University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia.
Participants A total of 415 pregnant women were recruited by using a systematic random sampling technique from 28 April 2020 to 12 June 2020.
Measurement The required data were collected through face-to-face interviews. The Perceived Stress Scale was used to assess perceived stress. The Edinburgh Postnatal Depression Scale and Oslo Social Support Scale 3 were used for associated factors. The data were analysed by using SPSS V.20. We also included sociodemographic, obstetrical and gynaecology, substance use and intimate partner-related factors. Logistic regression analysis was used to identify associated factors with perceived stress. Bivariate and multivariable logistic regression analyses were used to identify the effect of each independent variable with the outcome variable. A p value of less than 0.05 was considered to be statistically significant.
Results A total of 415 pregnant women participated in the study with response rate of 98.57%. The prevalence of perceived stress is found to be 13.7% (95% CI=10.4% to 17.1%). According to the multivariable logistic regression result, being a student (adjusted OR (AOR)=9.67, 95% CI=2.739 to 34.183), being at the first and third trimesters of gestational age (AOR=3.56, 95% CI=1.065 to 11.885; AOR=4.80, 95% CI=1.851 to 14.479, respectively), and having antenatal depression (AOR=3.51, 95% CI=1.628 to 7.563) were factors positively associated with perceived stress.
Conclusion The prevalence of perceived stress among pregnant people was relatively high. This study recommends that all pregnant people should be screened and treated for perceived stress particularly during the first and third trimesters. Emphasis should be given to early detection and treatment of antenatal depression. Pregnant students must be strongly evaluated and intervened for perceived stress.
- mental health
- public health
Data availability statement
Data are available upon reasonable request. The dataset is available on request by emailing the corresponding author at email@example.com.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The Perceived Stress Scale, which is validated and has high sensitivity and specificity, has been used to assess the outcome variable of perceived stress among pregnant women.
Due to the nature of cross-sectional study design, it could not report the temporal cause and effect relationship between perceived stress and associated factors.
Participants with minimal level of perceived stress may have less motivation to recall earlier exposure than those with moderate level and above.
Although stress is an integral part of one’s life, its occurrence during a period of pregnancy may surpass its level of normality and become problematic. High stress during pregnancy may affect the mother’s sleep quality, appetite, emotion and daily activity performance.1 2 The emergence of high stress during pregnancy is an indicator of accepting the pregnancy and the unborn baby, preparing for labour and motherhood, fear of unpleasant birth outcomes and a negative impact on the child’s early development.3–5 A number of research studies have shown that perceived stress during pregnancy may result in preterm birth, low birth weight, risk of gestational hypertension, and adverse health and behavioural outcomes for the unborn baby later.6 7 In addition, recent research studies have shown that perception of stress and anxiety is correlated with adverse effects on the mother and unborn baby, such as heart defects in the unborn baby, neurodevelopmental disorders later in the child and being small for gestational age.8–11
Even though research studies conducted to determine the magnitude of high stress during pregnancy are limited, some studies report that it ranges from 5.5 to 78%.12–18 A study conducted in Ireland reported 75.6% of women experienced perceived stress during pregnancy.19 Similarly, it has been reported to be 6%, 5.5%, 33.4%, 33.3%, 34.2%, 28.6%, and 11.6% and 23.1% in studies conducted in the USA,17 Iran,20 Saudi Arabia,18 India,21 Nepal,12 Ghana22 and Ethiopia,23 24 respectively.
A number of studies have also reported that pregnant women have an increased risk of adverse pregnancy outcomes in specified subgroups of women, such as women from low socioeconomic status, who were smokers and were underweight.25 26
Because pregnancy causes a number of physiological and physical changes, women are more likely to experience the onset and recurrence of high stress and emotional disorders.27 Particularly in the developing world, these conditions are highly correlated with factors including poverty,28 low social support,29 30 domestic violence,31–33 HIV/AIDS,34 and reproductive health outcomes and behaviours such as high parity, unwanted pregnancy, unsafe abortion, infertility, and pregnancy complications.35 36
Even though stress is a potential risk, not all pregnant women who develop stress have adverse complications.37 Besides, there is variability between studies regarding factors reported to increase the risk of perceived stress among women during pregnancy. For example, marital status has been reported to have significant associations with perceived stress in a study conducted in urban Thailand,38 which is not in agreement with previously conducted studies in Canada39 and Ethiopia.40 Another discrepancy between different studies was regarding psychosocial factors such as intimate partner violence or marital conflict, which were reported to have a significant association with perceived stress among pregnant women in a study done in Thailand38 and Canada39 but not in a study conducted in Ethiopia.40 As a result, the purpose of this study was to delve deeper into the factors that make pregnant women more vulnerable to high stress. Besides, this study aimed to assess COVID-19 determinants of perceived stress among pregnant women.
Objectives of the study
This study aimed to assess the prevalence of perceived stress and associated factors among pregnant women during the COVID-19 pandemic period in Northwest Ethiopia.
Study design and period
An institutional-based cross-sectional study was conducted from 28 April to 12 June 2020.
This study was conducted at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) antenatal care (ANC) clinic, Gondar, Amhara, Northwest Ethiopia. ANC service in the hospital has been given by obstetricians, gynaecologists and midwives in the outpatient departments. Approximately 11 000 pregnant women have been taking ANC service per year.
All pregnant women 18 years of age and older attending the ANC clinic at UoGCSH were included in the study. The study excluded severely ill pregnant women and those who had difficulty communicating for interviews during the data collection period.
Sample size determination
The sample size (n) was determined by using a single-population proportion formula by taking the following considerations: margin of error 5%, level of confidence (95%), the value of ‘p’ 50% and adding 10% non-response rate. Therefore, the final sample size was taken to 423.
Sampling technique and procedure
The total sample size was 423 with a non-response of 4. A systematic random sampling technique was employed for the selection of the sampling units. The value of ‘K’ was calculated by using the average pregnant population who had a visit in 1 month, which were 924 per month. Then ‘K’=924/423=2.182. Hence, the sample interval was 2. Therefore, individuals were chosen at regular intervals (every two) and the first participant was selected by daily sequences in the ANC clinic follow-up visit and the first study participant was selected by lottery method from the first two. The selected pregnant woman was directed by the facilitator to the place where the data collectors were working. A systematic random sampling technique was employed for all participants who fulfilled the inclusion criteria.
Data collection tool and procedure
Data were collected from study subjects using validated and pretested structured questionnaires. The data were collected by four BSc psychiatry professionals after 1-day training had been given and facilitated by the principal investigator.
The interview structure consists of eight parts:
Demographic characteristics: demographic data, which gave baseline information, were obtained from the participants, including age, ethnicity, religion, education, occupation, marital status and residency.
Obstetrics and gynaecological characteristics: information such as gestational age, parity, gravidity, abortion experience, type of pregnancy, and other comorbid illnesses such as pregnancy-related hypertension, gestational diabetes mellitus, and other illnesses was obtained from participants and their medical records.
Perceived stress characteristics: perceived stress resulting from perceptions of difficulty in control or ability to cope with life events during the last 1 month was measured by the 10-item Perceived Stress Scale (PSS).32 Responses are rated on a 5-point scale from 0 (never) to 4 (very often). Some of PSS scores are obtained by reversing responses (eg, 0=4, 1=3, 2=2, 3=1 and 4=0) to the four positively stated items (items 4, 5, 7 and 8) and then summed across all scale items. Scores range from 0 to 40, with higher scores indicating perceived higher stress. The Cronbach’s α for this instrument is between 0.84 and 0.86,33 and the Cronbach’s α of this study was 0.89.
Substance-related characteristics: behavioural factors including use of alcohol, use of tobacco, khat chewing and consumption of caffeinated substances were assessed by using structured questionnaires adapted from WHO ASSIST V.3.26 Participants who used substances such as tobacco, khat and alcohol only for non-medical purposes during their lifetime were considered ever substance users, whereas pregnant women who used substances such as tobacco, khat and alcohol only for non-medical purposes during the previous 3 months were considered current substance users.26
Caffeinated substance use: if one has consumed one or more of the following substances in the last month: coffee, tea or coca-cola.
Clinical-related characteristics: antenatal depression was assessed with the Edinburgh Postnatal Depression Scale (EPDS), which consists of 10 items. EPDS has been used successfully across diverse cultural settings. The EPDS questionnaire has been validated as effective in measuring prenatal depression.24 Items are rated on a 4-point scale from 0 (not at all) to 3 (yes, most of the time). Total scores range from 0 to 30. The screening tool has been validated for detecting depression in antepartum and postpartum samples in many countries. The instrument was validated in public health centres in Addis Ababa for postpartum women and showed a sensitivity of 84.6% and specificity of 77.0% at the cut-off score of 7/8 and a Cronbach’s α of 0.71.24 The cut-off point of EPDS among pregnant women is usually higher than postpartum women.27 Like other studies conducted globally and in Ethiopia, in this study, a cut-off point of 13 was used to identify pregnant women with depressive symptoms.28–30 Those pregnant women who scored 13 and above were categorised as having depression, while those who scored below 13 were non-depressed,29 and the Cronbach’s α of this study was 0.74.
Social support-related characteristics: consist of a 3-item questionnaire to determine the status of social support, which was assessed by using the Oslo Social Support Scale 3 validated tool. The Oslo 3-item Social Support Scale has a sum score scale ranging from 3 to 14 with three broad categories: ‘poor social support’ (3–8), ‘moderate social support’ (9–11) and ‘strong social support’ (12–14) with Cronbach’s α=0.88, and 86% sensitivity and 67% specificity.31
Intimate partner violence-related characteristics: consist of five questions to determine the status of intimate partner violence. The questionnaire was developed from a WHO multicountry study on violence against women; and if any questions on the screen were answered yes, the participant was considered positive for abuse.34
Data quality control
Face-to-face interviews with a structured questionnaire were used to collect data. The study subjects were informed about the general information on the study objectives as well as the opportunities or benefits that this study could bring. Finally, the filled questionnaires were checked for consistency and completeness daily. To assure the data quality, high emphasis was given in designing data collection instruments. The questionnaire was prepared in English and translated to Amharic and back to English to maintain consistency. The Amharic version of the questionnaire was used to collect information. One-day training was given for data collectors and supervisors by the principal investigator on the methods of data collection. The questionnaire was pretested 1 week before the actual data collection on 5% of the total sample size that was not included in the main survey.
Data processing and analysis
Data were coded and entered into Epidata software V.18.104.22.168 before being exported and analysed in SPSS V.20. Questionnaires that were incomplete were considered non-response. Then, the data were analysed to generate descriptive statistics such as means, medians, frequency, percentages and SD, using SPSS V.20. The goodness of fit was checked by Hosmer and Lemeshow (p=0.52). Multicollinearity (the values of variance inflation factor were <1.2) and Χ2 assumptions were made. Logistic regression analysis was used to calculate adjusted ORs to control for confounding variables with a 95% CI. Variables with a p value less than 0.2 in bivariate logistic regression analysis were entered into multivariable logistic regression to detect if there was a significant association. Outcome and independent variables were entered into bivariate one by one to detect association and into multivariable logistic regression to show the presence and strength of association. Statistical significance was determined at a p value of less than 0.05.
Patient and public involvement
In this study, participants were pregnant women who were attending ANC at UoGCSH. Seriously sick patients were excluded. We did not involve participants in designing the study and the recruitment process. The result of this study has been submitted to the Department of Psychiatry, University of Gondar, and the UoGCSH.
A total of 415 pregnant women participated in the study, with a response rate of 98.57%. From those participants, the prevalence of perceived stress was 13.7%, with a 95% CI of 10.4 to 17.1. The mean age of the participants was 28 years (SD±5.46), while in age classification, more than half (54.2%) were within the range of 26–35 years old. Most of the participants (391, or 94.2%) were married and nearly three-fourths (72.8%) were Orthodox by religion. More than one-third (156, 37.6%) of the participants had primary education and more than a quarter (118, 28.4%) had a diploma or above. Almost all of the (406, 97.8%) study population were Amhara in ethnicity, and 168 (40.5%) were housewives in occupation. Almost all (94.2%) of the participants lived in cities (table 1).
Characteristics of gynaecological, obstetrical and other comorbid illnesses
More than half of the participants (246, 59.3%) were in their third trimester, and more than two-thirds (292, 70.4%) were having their second or subsequent pregnancy. More than one-third (149, 35.9%) had experience of labour two or more times before, and nearly one-third (133, 32%) of the participants had two or more children alive. Around 62 (14.9%) had experienced an abortion in their lifetime and 368 (88.7%) were wanted pregnancies in the type of current pregnancy. Fifty-eight (14%) of the participants had other comorbid illnesses; and of those, 37 (63%) and 16 (27.6%) had pregnancy-related hypertension/pre-eclampsia and gestational diabetes mellitus, respectively (table 2).
Behavioural and psychosocial characteristics of the participants
Almost all (411, 99%) of the participants had never smoked a cigarette in their lives, and no one had smoked a cigarette in the previous 3 months. About 48 (11.6%) of the study participants used alcohol in their lifetime and 26 (6.3%) used alcohol within the last 3 months. Among those pregnant women who used alcohol during the last 3 months, more than half (53.8%) used tella (local beer). Regarding khat chewing, five (1.2%) of participants ever chewed khat, but there were no chewers reported during the last 3 months.
Mental illness and psychosocial factors
Among study participants, 69 (16.6%) had depression; and of those with social support, 103 (24.8%) had poor and nearly one-third (125, 30.1%) had strong social support. In regard to intimate partner violence, 19 (4.6%) have been abused physically or emotionally during their lifetime; 15 (3.6%) have been slapped, kicked or otherwise physically hurt by someone important to them during the last year; and of those, 9 (60%) have been abused by their husbands. Thirteen (3.1%) of the participants have been hit, slapped, kicked or otherwise physically hurt by someone important to them during their current pregnancy; and of those, 10 (71.4%) were abused by their husband.
All of the study participants did not test positive for COVID-19 during the data collection period. Six (1.5%) were reported as they were in isolation for 2 weeks. All of participants reported as they did not discontinue their ANC follow-up since the pandemic period. The source of information about COVID-19 for the majority of participants (368, 88.7%) was reported to be mass media, followed by health professionals for 126 (30.4%) of study participants.
Associated factors of perceived stress among pregnant women
Maternal age, marital status, occupational status, residence, gestational age, type of pregnancy, prenatal depression and intimate partner violence were variables that had a p value less than 0.2 in bivariate logistic regression. Of those, being students, first and third trimesters of gestational age and prenatal depression were found to be significantly associated with perceived stress among pregnant women in multivariable logistic regression analysis at a p value of less than 0.05.
The prevalence of perceived stress among pregnant women was found to be 9.6 times higher among pregnant students as compared with housewives (adjusted OR (AOR)=9.67, 95% CI=2.739 to 34.183). The odds of having perceived stress were 3.5 and 4.8 times higher in the first and third trimesters, respectively, compared with the second trimester (AOR=3.56, 95% CI=1.065 to 11.885; AOR=4.80, 95% CI=1.851 to 14.479). Pregnant women who had prenatal depression were nearly five times more likely to develop perceived stress as compared with pregnant women without prenatal depression (AOR=4.80, 95% CI=1.851 to 14.479) (table 3).
From this study, the overall prevalence of perceived stress among pregnant women attending an ANC clinic at the UoGCSH was 13.7% (95% CI=10.4% to 17.1%). The result is in line with a study conducted in Ethiopia (11.6%).24 The result of this study is higher than studies conducted in the USA (6%)17 and Iran (5.5%).20 The higher prevalence in our study result could be attributed to a difference in the study periods. Our study was conducted during the very difficult period of the COVID-19 pandemic. Such pandemic periods have been reported to negatively affect the health of pregnant women. For example, a recent study during the COVID-19 pandemic period indicated that there is increased anxiety and poor quality of sleep levels. This in turn may further aggravate the sleep disturbance caused by the physiological effects of pregnancy, which may increase the stress level of the pregnant woman.41 Moreover, it might be because of a lack of social support, which is vital in decreasing stress and anxiety in pregnant women during the pandemic period, when lockdowns and curfews were implemented as preventive methods.42 43 Other possible reasons for this discrepancy might be a difference in the characteristics of the participants, sociocultural lifestyles, sampling techniques and use of different measurement tools for the outcome.20
However, the result of this study is lower than studies conducted in Saudi Arabia (33.4%),18 India (33.3%),14 Nepal (34.2%)12 and Ghana (28.6%).22 The possible reason for these variations might be sample size and sampling technique used in a study conducted in Ghana,22 difference in cut-off score for the PSS with that of an Indian study (a higher cut-off score is used for this study)14 and characteristics of the participants and difference in culture and coping skills.12 14 18 22
Regarding factors found to be associated with perceived stress among pregnant women, being a student was among the sociodemographic categories that were associated with perceived stress during pregnancy. The likelihood of developing perceived stress among pregnant women who were students at the time of the study was more than 9.6 times as compared with housewives. The possible reasons might be an unpleasant feeling of tension and anticipated frustration secondary to academic-related demands and expectations from significant others.44 It might also be because of the increased cortisol release during the examination, which is known to be linked with a change in immunity functioning, which can be checked evidently with a change in IgA.45 46 First and third trimester pregnancy terms were significantly associated with perceived stress. Participants who were in their first and third trimesters had the odds of having perceived stress nearly four and five times as compared with being pregnant in their second trimester, respectively. The findings of this study were supported by study findings in Ethiopia23 and Nepal12 for first trimester pregnancy. It might be because pregnancy, particularly the first trimester, is a period of enormous biological, psychological, and social challenges for the mother and a time of making significant life changes. These changes might in turn be linked to emotional disturbances and contribute to increased perceived stress in pregnant women.47 It might also be due to the first trimester being associated with significantly higher levels of nausea, vomiting and fatigue. These have also been linked with higher perceived stress among pregnant women.48
Having antenatal depression was another factor found to have a significant association with perceived stress among pregnant women. Pregnant women who had prenatal depression were nearly five times more likely to develop perceived stress as compared with pregnant women without prenatal depression. Even though depression is more serious and long-lasting than stress, disease-related factors like decreased coping skills, poor quality of life and decreased immunity might lead participants to further experience increased stress.49 50 It might be because depressive symptoms are associated with higher levels of maternal serum inflammatory markers during pregnancy.51 These inflammatory biomarkers have also been reported to have a significant contribution to the increased release of stress hormones, which in turn contributes to increased perceived stress among pregnant women.45 46 Moreover, the strong association might also be because of the increased perceived stress from the intrapsychic conflict of women between pleasurable expectations regarding their pregnancy outcome and their own experience of symptoms of depression like sadness and irritability.52 Moreover, the association might be because of items both in PSS and EPDS assessing similar information, and the effect of multicollinearity might lead to the strong association between perceived stress and prenatal depression.
Limitation of the study
Due to the nature of cross-sectional study design, it was not possible to report the temporal cause and effect relationship between perceived stress and antenatal depression. Participants with a minimal level of stress might be less motivated to recall their exposure than those with a moderate level of stress and above.
Conclusions and recommendations
The prevalence of perceived stress among pregnant people was relatively high. Being a student, first and third trimesters, and antenatal depression were factors significantly associated with perceived stress among pregnant women. This study recommended that all pregnant people should be screened and treated for perceived stress, particularly during the first and third trimesters. Early detection and treatment of antenatal depression should be given emphasis. Pregnant students must be thoroughly evaluated and treated for perceived stress.
Data availability statement
Data are available upon reasonable request. The dataset is available on request by emailing the corresponding author at firstname.lastname@example.org.
Patient consent for publication
This study involves human participants, and an ethical clearance and an official letter for permission were obtained from the institutional review board (IRB) of the University of Gondar with reference number 1868/02/2020. Then, the letters were submitted to the UoGCSH Department of Gynaecology and Obstetrics outpatient unit. The details of the study were explained to all participants before starting data collection. Written consent was obtained from each participant before starting data collection. Study participants were told that they had the right not to participate in the study. The privacy of study participants and the confidentiality of information are kept at every stage of data processing. Participants gave informed consent to participate in the study before taking part.
The authors would like to acknowledge the University of Gondar for issuing ethical clearance. The authors are thankful to the University of Gondar Comprehensive Specialized Hospital ANC staff and study participants.
Contributors MSB conceived the idea and had major roles in the review of literature, extraction, proposal writing, data collection and analysis. GMT and ETG had a role in data commenting, editing of the proposal as well as the report. All authors contributed equally to the analysis, writing, drafting and editing. MSB is acting as guarantor. All the authors read and gave final approval of the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.