Objective
We sought to identify factors associated with high antenatal psychosocial stress and describe the course of psychosocial stress during pregnancy.
Study Design
We performed a cross-sectional analysis of data from an ongoing registry. Study participants were 1522 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2008. Multiple logistic regression identified factors associated with high stress as measured by the Prenatal Psychosocial Profile stress scale.
Results
The majority of participants reported antenatal psychosocial stress (78% low-moderate, 6% high). Depression (odds ratios [OR], 9.6; 95% confidence interval [CI], 5.5–17.0), panic disorder (OR, 6.8; 95% CI, 2.9–16.2), drug use (OR, 3.8; 95% CI, 1.2–12.5), domestic violence (OR, 3.3; 95% CI, 1.4–8.3), and having ≥2 medical comorbidities (OR, 3.1; 95% CI, 1.8–5.5) were significantly associated with high psychosocial stress. For women who screened twice during pregnancy, mean stress scores declined during pregnancy (14.8 ± 3.9 vs 14.2 ± 3.8; P < .001).
Conclusion
Antenatal psychosocial stress is common, and high levels are associated with maternal factors known to contribute to poor pregnancy outcomes.
Psychosocial stress in pregnancy, defined as “the imbalance that a pregnant woman feels when she cannot cope with demands…which is expressed both behaviorally and physiologically,” has not routinely been measured in everyday obstetric practice. It has recently come to the forefront of policy, however, with the American College of Obstetricians and Gynecologists (ACOG) releasing a 2006 committee opinion stating that psychosocial stress may predict a woman’s “attentiveness to personal health matters, her use of prenatal services, and the health status of her offspring.” In this committee opinion, ACOG advocated screening all women for psychosocial stress and other psychosocial issues during each trimester of pregnancy and the postpartum period.
Despite these recommendations the prevalence of antenatal psychosocial stress is unclear and its influence on maternal health is likely underestimated. Further, little research exists regarding which factors contribute to or coexist with psychosocial stress during pregnancy. In the few studies conducted to date, associations have been noted between antenatal psychosocial stress and domestic violence, substance use, depressive symptoms, psychiatric diagnoses, poor weight gain, and having a chronic medical disorder. Many of these studies were limited, however, in their sample size, select populations, or assessment of potential covariates (eg, use of nonvalidated measures or medical records only). Some of these identified factors are known to be associated with adverse birth outcomes (eg, preterm delivery, low birthweight ), so determining their associations with psychosocial stress is paramount.
Research regarding the factors associated with high psychosocial stress during pregnancy has potential to provide targets for interventions, leading to an increase in maternal well-being and a potential decrease in adverse birth outcomes. The primary aims of this study were to identify factors associated with high antenatal psychosocial stress and describe the course of psychosocial stress during pregnancy.
Materials and Methods
Design, sample, setting, and time frame
We studied pregnant women enrolled in a longitudinal study of antenatal care at a single university obstetric clinic. The clinic serves a group of women with diversity in race, socioeconomic status (SES), and medical risk, with a payer mix of 46.5% private insurance, 51.6% Medicaid, and 1.9% self-pay. Clinic providers include attending physicians, fellows, residents, and midwives. As part of a psychosocial screening program, questionnaires measuring stress and mood were introduced in January 2004. Questionnaires were designed to be distributed by clinical staff as part of routine clinical care to all women at least once during pregnancy with the goal of 2 times: first during the early second trimester and again in the third trimester. All women receiving ongoing obstetric care and completing at least 1 questionnaire from January 2004 through March 2008 were eligible for inclusion in the study. Exclusion criteria included age <15 years at the time of delivery and inability to complete the clinical questionnaire due to mental incapacitation or language difficulties (ie, no interpreter available). Clinical staff were asked to contact and consent potentially eligible subjects at the time of screen completion. All procedures were approved by the University of Washington’s institutional review board.
Measures
Data were collected from self-report questionnaires and from automated medical records. The questionnaire included inquiry regarding demographic characteristics, social history, medication use, general health history, past obstetric complications, as well as validated measures assessing psychosocial stress, depression and panic disorder, tobacco use, alcohol use, drug use, and domestic violence. Maternal age and parity were obtained from the automated medical record.
Psychosocial stress was measured using the Prenatal Psychosocial Profile stress scale, which has been validated for use in pregnant populations. It is an 11-question survey using a Likert response scale with possible scores ranging between 11 and 44 ( Appendix ). The scale’s validity and reliability have been supported among ethnically diverse rural and urban pregnant women. Several recent studies have used this instrument to measure psychosocial stress. In these studies, mean stress scores ranged from 17-23. The recommended cutoff for high stress depends on the population studied and the patient characteristics; there are no recommendations for differentiating low to moderate stress. In the 2 studies that have established cutoffs for high stress, one used scores above the mean plus 2SD (score >26) whereas another chose a set percentile of 25% (score ≥23). Both of theses studies had predominantly low SES participants. In our heterogeneous SES population, we chose a cutoff of scores above the mean plus 2SD, corresponding to a score of ≥23 for our sample.
Depression and panic disorder were assessed using the Patient Health Questionnaire short form (15 items), which yields diagnoses for major depression, minor depression, and panic disorder. In a study of 3000 obstetric-gynecologic patients, high sensitivity (73%) and specificity (98%) for the depression items were demonstrated for a diagnosis of major depression based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . This was also true for diagnostic items related to panic disorder (sensitivity 81%, specificity 99%). In our study, women meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major or minor depression on the Patient Health Questionnaire-9 were classified as experiencing current depression. The criteria for major depression require the subject to have, for at least 2 weeks, ≥5 depressive symptoms present for more than half the days, with at least 1 of these symptoms being depressed mood or anhedonia. The criteria for minor depression require the subject to have, for at least 2 weeks, 2-4 depressive symptoms present for more than half the days, with at least 1 of these symptoms being depressed mood or anhedonia. Women were classified as having current panic disorder if they answered “yes” to 5 diagnostic criteria for panic disorder.
Tobacco, alcohol, and drug use were assessed using the Smoke-Free Families Prenatal Screen, the Alcohol T-ACE (‘Tolerance’: How many drinks does it take to make you feel high? Have people ‘annoyed’ you by criticizing your drinking? Have you ever felt you ought to ‘cut down’ on your drinking? ‘Eye-opener’: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?), and the Drug CAGE (Have you ever felt you should ‘cut down’ on your drinking? Have people ‘annoyed’ you by criticizing your drinking? Have you ever felt bad or ‘guilty’ about your drinking? ‘Eye opener’: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?). The Smoke-Free Families Prenatal Screen was specifically developed to maximize disclosure of smoking status during pregnancy and any current smoking is classified as tobacco use. Both the T-ACE and the Drug CAGE assess substance use during the current pregnancy as well as in the 12 months prior to pregnancy to identify all women at risk for use. The T-ACE was developed to identify at-risk drinkers, has been validated in a pregnant population, and has increased sensitivity compared to the Alcohol CAGE. Sensitivity and specificity of identifying at-risk drinkers are 69% and 89% when a score of ≥2 on the T-ACE is used. The Drug CAGE, developed from the original CAGE to identify problem illicit drug use, has been validated in pregnant women with a cutoff score of ≥3 identifying problem drug use. In this study, women were considered as at-risk drinkers or problem drug users if they met criteria for risk drinking or problem drug use during pregnancy and/or in the 12 months prior to pregnancy.
The 3-question Abuse Assessment Screen assesses physical and sexual violence during the past year and during pregnancy. This screen has been used both as a clinical screening tool with established validity and test-retest reliability, and for research purposes as a dichotomous measure of abuse. Consistent with previous research studies, we classified women as positive for domestic violence if they answered “yes” to any of the 3 abuse questions.
Women were considered as having high medical comorbidity if they self-reported ≥2 chronic medical problems outside of pregnancy (eg, asthma, hypertension, diabetes, or cardiovascular problems). A history of pregnancy complications was recorded for patients who self-reported ≥1 significant pregnancy complications (eg, gestational diabetes, preeclampsia, eclampsia, preterm delivery, or placental abruption) in a prior pregnancy. Other demographics including employment, education, and marital status were dichotomized as shown in Table 1 .
| Characteristic | Total (n = 1522) | High stress | Test statistic ( t or χ 2 ) | P value | |
|---|---|---|---|---|---|
| Yes (n = 91) | No (n = 1421) | ||||
| Age, y | 30.4 (±6.3) | 28.0 (±6.6) | 30.6 (±6.3) | 3.676 | < .001 |
| Gestational age, wk a | 23.5 (±7.3) | 25.0 (±7.5) | 23.4 (±7.3) | 1.917 | .058 |
| Education | 36.433 | < .001 | |||
| ≤High school | 19.3% (n = 293) | 42.9% (n = 39) | 17.9% (n = 254) | ||
| >High school | 73.5% (n = 1118) | 48.4% (n = 44) | 75.1% (n = 1067) | ||
| Employment | 39.171 | < .001 | |||
| Unemployed | 11.1% (n = 169) | 30.8% (n = 28) | 9.9% (n = 141) | ||
| Other b | 81.5% (n = 1241) | 60.4% (n = 55) | 83.0% (n = 1179) | ||
| Marital status | 43.522 | < .001 | |||
| Married/partnered | 81.1% (n = 1234) | 58.2% (n = 53) | 82.6% (n = 1174) | ||
| Other c | 11.8% (n = 179) | 33.0% (n = 30) | 10.5% (n = 149) | ||
| Race | 26.075 | < .001 | |||
| White | 66.9% (n = 1018) | 56.0% (n = 51) | 67.6% (n = 961) | ||
| Black | 7.6% (n = 116) | 14.3% (n = 13) | 7.2% (n = 102) | ||
| American Indian or Native Alaskan | 2.2% (n = 34) | 4.4% (n = 4) | 2.1% (n = 30) | ||
| Asian | 10.9% (n = 166) | 6.6% (n = 6) | 11.2% (n = 159) | ||
| Native Hawaiian or other Pacific Islander | 1.2% (n = 18) | 1.1% (n = 1) | 1.1% (n = 16) | ||
| Mixed | 5.5% (n = 83) | 14.3% (n = 13) | 4.9% (n = 69) | ||
| Undeclared | 5.7% (n = 87) | 3.3% (n = 3) | 5.9% (n = 84) | ||
| Ethnicity | 2.302 | .316 | |||
| Hispanic | 9.0% (n = 137) | 8.8% (n = 8) | 9.1% (n = 129) | ||
| Non-Hispanic | 81.1% (n = 1234) | 76.9% (n = 70) | 81.5% (n = 1158) | ||
| Undeclared | 9.9% (n = 151) | 14.3% (n = 13) | 9.4% (n = 134) | ||
| Parity | 0.756 | .385 | |||
| Primiparous | 53.7% (n = 818) | 58.2% (n = 53) | 53.6% (n = 761) | ||
| Multiparous | 46.3% (n = 704) | 41.8% (n = 38) | 46.4% (n = 660) | ||
| Current cigarette smoking | 75.808 | < .001 | |||
| No | 88.8% (n = 1352) | 67.0% (n = 61) | 90.6% (n = 1288) | ||
| Yes | 7.4% (n = 112) | 30.8% (n = 28) | 5.9% (n = 84) | ||
| Alcohol use | 1.147 | .284 | |||
| No | 80.7% (n = 1228) | 80.2% (n = 73) | 85.0% (n = 1208) | ||
| Yes | 14.9% (n = 212) | 17.6% (n = 16) | 13.7% (n = 195) | ||
| Drug use | 45.139 | < .001 | |||
| No | 95.9% (n = 1460) | 87.9% (n = 80) | 96.6% (n = 1372) | ||
| Yes | 1.6% (n = 23) | 9.9% (n = 9) | 1.0% (n = 14) | ||
| Domestic violence | 73.017 | < .001 | |||
| No | 95.4% (n = 1452) | 80.2% (n = 73) | 96.6% (n = 1372) | ||
| Yes | 3.5% (n = 54) | 19.8% (n = 18) | 2.5% (n = 36) | ||
| Current depression (major or minor) | 221.765 | < .001 | |||
| No | 90.7% (n = 1381) | 47.3% (n = 43) | 93.5% (n = 1329) | ||
| Yes | 9.1% (n = 138) | 52.7% (n = 48) | 6.3% (n = 90) | ||
| Panic disorder | 101.189 | < .001 | |||
| No | 96.6% (n = 1470) | 79.1% (n = 72) | 97.7% (n = 1389) | ||
| Yes | 3.1% (n = 47) | 20.9% (n = 19) | 2.0% (n = 28) | ||
| ≥2 chronic health problems | 51.307 | < .001 | |||
| No | 74.8% (n = 1139) | 45.1% (n = 41) | 76.8% (n = 1091) | ||
| Yes | 18.9% (n = 287) | 46.2% (n = 42) | 17.0% (n = 242) | ||
| History of pregnancy complications | 2.727 | .099 | |||
| No | 64.7% (n = 984) | 56.0% (n = 51) | 65.2% (n = 927) | ||
| Yes | 32.3% (n = 492) | 39.6% (n = 36) | 31.8% (n = 452) | ||
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