Factor structure of the Prenatal Distress Questionnaire
Introduction
Pregnancy is characterised by physiological, social and emotional changes, as well as parenting concern and financial demands, which are all potential sources of stress (Yali and Lobel, 2002). Stress is a relatively broad concept often loosely defined in health literature. Key components include the presence of internal and external stressors, how a woman appraises these stressors and how she responds to the stressors (Cohen et al., 1997). An individual’s life experience, such as social support and poverty, will also contribute to the experience of stress. Anxiety is a related but separate concept which is a recognised state of distress that may or may not be present in the stress response (Latendresse, 2009). There is evidence to suggest that the stress response varies through the course of pregnancy, and that events occurring early in pregnancy are experienced as more stressful than those same events occurring later in pregnancy (Glynn et al., 2008).
A significant body of literature now exists demonstrating a relationship between maternal stress and adverse pregnancy outcome, in particular prematurity (Alderdice and Lynn, 2009, Latendresse, 2009). It has also been associated with an increase in unhealthy behaviours in pregnancy (Lobel et al., 2008), impaired cognitive and social developmental outcomes (Wadha, 2005), and lower neonatal neurobehavioural assessment (Talge et al., 2007). With this in mind, it is important to be able to identify women experiencing stress during pregnancy and to find additional ways of supporting these women to alleviate stress. In addition, the timing of assessment is critical to be able to identify women at risk of going into labour, and to allow for the introduction of interventions to treat preterm labour and prevent preterm birth.
A major barrier to introducing routine assessment of stress into antenatal care is identifying a reliable, valid and clinically relevant measure to use. Many assessment tools exist in the research literature measuring both general stress and pregnancy-specific stress. Measures of general stress have been used to predict birth outcome and the postnatal development of the infant, including the State-Trait Anxiety Inventory (Spielberger et al., 1970) and the Perceived Stress Scale (Cohen et al., 1983). However, these questionnaires were not designed to assess stress specifically in relation to pregnancy, and have yielded inconsistent associations with birth outcomes across studies (Lobel et al., 2008). A number of researchers have indicated that pregnancy-specific stress may be a more powerful contributor to birth outcomes than stress from sources unrelated to pregnancy (Huizink et al., 2004, Lobel et al., 2008).
Section snippets
Pregnancy-specific stress
Pregnancy-specific stress refers to maternal fears and worries related to pregnancy (Huizink et al., 2004), and include the health of the fetus, physical symptoms, parenting, relationships with others, and labour and delivery (Levin, 1991, Da Costa et al., 1999, Yali and Lobel, 1999, Huizink et al., 2004). Huiznik et al. (2004) reported that pregnancy anxiety, rather than general anxiety, correlated with neuroendocrine changes during pregnancy and predicted birth outcome. Lobel et al. (2008)
The Prenatal Distress Questionnaire
The PDQ was designed to assess specific worries and concerns pertaining to pregnancy, including concerns regarding medical problems, physical symptoms, parenting, relationships, bodily changes, labour and childbirth, and the health of the infant. The PDQ contains 12 concise items, has good face validity, and can be completed in less than five minutes in a health-care setting. Reported reliability and validity data for the original scales can be found in three studies from the USA (Yali and
Design
A cross-sectional survey study design was used to collect data from healthy, low-risk pregnant women attending a large, urban maternity unit in Northern Ireland.
Participants
Women were approached during their first antenatal care appointment at 14–16 weeks of gestation within the antenatal outpatients’ clinic on a consecutive basis. Women who were over the age of 16 years and who self-reported that they were healthy and at low risk of developing complications were invited to participate. In total, 278
Data analysis
All unique identifiers were removed in accordance with research ethics procedures and stored separately in a password-protected file. Double data entry was carried out on 20% of the questionnaires to validate data-recording methods and minimise processing errors. Data were entered into Statistical Package for the Social Sciences version 15 (SPSS Inc, Chicago, IL, USA) to conduct an EFA on the 12 items of the PDQ. EFA is a large sample procedure, and although there is no specific rule for sample
Findings
Demographic details and characteristics of the study sample are provided in Table 1. The majority of participants were aged between 21 and 35 years (77%, n=203), and 74.5% (n=196) were married, remarried or cohabiting. Over 44% (n=116) of those who participated in the study were experiencing their first pregnancy. Of the 147 women who had had previous pregnancies, 40% (n=106) had experienced one or two pregnancies and 16% (n=41) had experienced three or more pregnancies. Sample characteristics
Suitability for factor analysis
Total scores on the PDQ scale ranged from 0 to 46 (mean=15.1; SD=7.365). The item to variable ratio was approximately 1:21. The KMO value was 0.79 and Bartlett’s test of sphericity was highly significant (approximately ×2=1110; df=66; p<0.0001), indicating that the inter-correlation matrix was appropriate for factor analysis.
Three factors had eigenvalues greater than one, and the scree plot also suggested a three factor solution. Table 2 presents the factor coefficients for each item. All three
Discussion
Analysis of individual items showed that women in this study were most concerned about healthy diet, labour and delivery, and physical symptoms, and least concerned about changes in attachment to the baby and relationship with the father. Most studies presenting data on the PDQ focus on the total score rather than individual items, with the exception being Yali and Lobel (1999) who report that women in their study were especially worried about preterm delivery, physical symptoms, and labour and
Study limitations and research implications
The PDQ was administered to a large, representative sample of low-risk women in the second trimester of pregnancy, providing valuable data for exploring the construct of pregnancy-specific stress as measured by the PDQ. However, as the questionnaire was only given at one point in pregnancy, it is unclear what variations there might be in responses at different times in pregnancy and in the stability of the factor structure over time. Although other studies have demonstrated that the PDQ has
Implications for practice
Pregnancy-specific stress is not a single construct, but can be differentiated into several aspects. Those measured by the PDQ relate to concerns about birth and the baby, body image/weight and emotions/relationships with partner and others. Recent research suggests that high pregnancy-specific maternal stress is associated with prematurity (Latendresse, 2009), and early knowledge about the source of stress to inform appropriate intervention is important. Although a pregnancy-specific stress
Acknowledgements
We would like to thank all the women who took the time to participate in this study.
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