Investigating the
relationship between anxiety and perceived stress with coping strategies
adopted in pregnant women during the COVID-19 pandemic
Fatemeh Shabani 1, Seyedeh
Hajar Sharami 1*, Roya Faraji 1,
Habib Eslami-Kenarsari 2, Asiyeh Namazi 3
1 Reproductive Health Research Center, Department of
Obstetrics & Gynecology, Al-zahra Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
2 Vice-Chancellorship
of Research and Technology, Guilan University of
Medical Science, Rasht, Iran
3 Midwifery Department, Rasht branch, Islamic Azad
University, Rasht, Iran
Corresponding Authors: Seyedeh
Hajar Sharami
* Email: sharami@gums.ac.ir
Abstract
Introduction: The COVID-19 pandemic has led to mental problems, including stress and
anxiety, for people, especially pregnant women. Identifying strategies to deal
with stress is important and can help pregnant mothers to adapt to stressful
life factors such as the conditions of the COVID-19 pandemic. The present study
was designed and implemented with the aim of investigating the relationship
between anxiety and perceived- stress with the coping strategies of pregnant
women referring to Al-Zahra Hospital in Rasht.
Methods: The current study
was conducted on 221 pregnant women using a cross-sectional analysis method.
The required information was collected by the self-report method through
demographic questionnaires, Corona disease anxiety (CDAS), Cohen's perceived
stress, and Endler and Parker's coping strategies questionnaire. Data were
analyzed using SPSS version 22 software using Spearman's correlation
coefficient and linear regression tests. The significance level of the tests
was considered as P < 0.05.
Results: 53.4% of women had moderate anxiety and 60.6% of pregnant women had
high levels of perceived stress. There was a direct and significant correlation
between anxiety-perceived stress and emotion-focused strategy (P<0.001).
Conclusion: The present study showed high perceived stress and moderate anxiety in
pregnant women during the COVID-19 pandemic and their relationship with
emotion-focused coping strategies.
Keywords: Coping strategies, Anxiety, Perceived stress, Self-care, Coronavirus
Introduction
COVID-19
is a new respiratory disease that is spreading rapidly worldwide the world and
was declared a pandemic by the World Health Organization on March 11, 2020
(1). In addition
to physical complications (2) and mortality,
the COVID-19 pandemic also causes psychological disorders in members of society
(3) and especially in pregnant women (4). The mental
health of women, especially pregnant women, is crucial due to their role in the
family. Studies have shown that during the COVID-19 pandemic, women are
experiencing higher rates of anxiety, depression, and stress compared to men (5-7). Due to
physiological and psychological changes during pregnancy, this period is one of
the most sensitive stages of a woman's life. These changes in pregnant women
lead to the induction of great changes, including physiological and
psychological changes, which cause the emergence of psychopathological
disorders, including stress and anxiety (8).
Mood and anxiety disorders are among the most
common problems during pregnancy, which is why half of pregnant women
experience pregnancy-specific anxiety (9). With the
Prevalence of infectious diseases, such as the stressful conditions during the COVID-19
pandemic and the changes created due to the existing conditions, widespread
anxiety disorders during pregnancy have intensified so that in pregnant women,
symptoms of anxiety (57%) and depression (37%) compared to the period before
Corona shows an increase (10, 11). Despite the
prevalence of corona disease, fear and stress in pregnant women due to the fear
of infection and transmission to the fetus have caused excessive and obvious
anxiety with negative psychological effects in this vulnerable group (12). Due to
physiological changes, these worries increase in the first and third trimester
compared to the second trimester (13, 14). During the COVID-19
pandemic, pregnant women in the first trimester reported increased stress at
work, increased stress from home, and greater feelings of anxiety than pregnant
women in the second and third trimesters. In addition, pregnant women in the
second trimester of pregnancy felt more helpless than pregnant women in the
first and third trimesters of pregnancy (13). The stress
hormone cortisol, along with the release of inflammatory markers like
cytokines, can lead to negative consequences for both mother and fetus due to
elevated levels of these chemicals (15).
The
negative effects of maternal anxiety and stress during pregnancy lead to
complications such as postpartum depression and mood disorders (16), preeclampsia,
pregnancy-related nausea and vomiting, increased blood pressure, and increased
number of unplanned cesarean section. Furthermore, due to the increase of
glucocorticoids, their negative effects on the fetus include weight loss,
increased fetal birth defects, infant mortality (17, 18), as well as
fetal and neonatal complications such as premature delivery (19, 20), low birth
weight, low Apgar score, neonatal abnormalities such as cleft palate,
hospitalization, and developmental delay. These babies often have symptoms such
as severe bloating and heart pain, insomnia at night, and constant crying (21-23). Although
studies show that fear and anxiety caused by the illness can increase
preventive behaviors in a person, fear and anxiety related to the disease are are directly related to psychological problems (9, 24). The World
Health Organization announced in 2014 that mental disorders in women not only
affect the individual, but also their children and other family members, and
thus the society, as well as future generations in economic planning (25).
Coping
is a person's first reaction to stressful events (26).
Interestingly, some research suggests that coping can also moderate the effects
of stress on mental health (27, 28). But many
studies indicate the relationship of coping strategies with mental health
consequences during the COVID-19 pandemic (9, 11, 23, 29,
30). Therefore, it
is important to identify stress coping strategies and it can help pregnant
mothers to adapt to the stressful factors of life, especially the existing
conditions affecting the COVID-19 disease. There are three types of coping
strategies: Problem-focused strategy, emotional-focused strategy, and avoidance
coping strategy (31, 32). In
Problem-focused strategy, the person tries to manage or modify the stressful
situation, and this type of coping is useful when faced with a controllable
stressor (33). People who
use problem-based coping reduce their stress levels by gathering available
information to deal with the stressor (18, 34). The more
problem-focused coping strategies a person uses, the better their mental health
and the less anxiety and worry they display, and vice versa. Problem-focused
coping strategies are associated with more coping, and emotion-focused coping
strategies are associated with less coping (35, 36). Avoidant and
emotion-focused coping strategies act as mediators through which experiences of
COVID-19 is indirectly related to mental health during pregnancy (9, 23).
Prior
to the COVID-19 pandemic, a study was conducted on a group of pregnant women
which revealed that avoidant coping strategies such as refusal,
non-involvement, and self-blame were associated with an increased risk of
mental health issues. On the other hand, emotion-focused coping strategies were
found to be less associated with mental health issues, while problem-focused
coping strategies were not found to be related to mental wellbeing issues. In a
recent study conducted on non-pregnant women prior to the outbreak, it was found
that maladaptive coping strategies such as avoidance were associated with
increased levels of stress and anxiety. During outbreaks, these maladaptive
coping strategies were found to be associated with even higher levels of stress
and anxiety (8, 9, 29). It seems that
when faced with stressors that are beyond our control, utilizing
emotion-focused coping strategies proves to be more effective. On the other
hand, when dealing with situations that we have some level of control over,
employing problem-focused coping strategies tends to yield better results (37). The mental
health of pregnant women is a high-risk concern in society, especially during
stressful conditions such as the coronavirus pandemic. Effective interventions
can be taken to reduce stress by adopting coping strategies and eliminating
inappropriate solutions. By understanding the coping strategies adopted by
pregnant women in the face of perceived anxiety and stress, necessary
interventions can be implemented to improve their mental health. Due to the
scarcity of studies related to coping strategies during pregnancy, this study
aims to investigate the relationship between perceived anxiety and stress and
coping strategies adopted by pregnant women, highlighting the importance and
necessity of this topic.
Methods
This
cross-sectional analytical study was conducted after receiving the code of Guilan University of Medical Sciences from June to
September 2022 and with a random sampling of 221 pregnant women referred to the
educational-therapeutic center of Al-Zahra Hospital in Rasht. To be considered
for the study, patients must have singleton pregnancies, have ultrasound
confirmation at 8 weeks, basic literacy level or above, know the Persian
language, consent to participate in the application process, and meet certain
conditions such as substance abuse risk factors. Patients who have had physical
illness, undergone medical consultations or had experienced significant stress
in the last six months (such as a loved one's divorce or death), were not
willing to cooperate with others, and completed the questionnaire unfinished..
Method
of determining sample size
The
sample size was obtained using the study of Basharpoor
et al (38) and the study
of Masjoudi et al (24) The initial
sample size was obtained from the following formula, but the questionnaires
were given to 256 pregnant women in this study.
Measures
1. Demographic
information questionnaire: personal, social, midwifery profile
questionnaire which is a questionnaire of 23 questions made by the researcher,
12 questions about age, education, occupation, level of education of spouse,
occupation of a spouse, number of pregnancies, history of abortion, amount of
income Household, residence status, covered by health insurance, current week
of pregnancy and additionally, there are 11 questions addressing potential risk
factors in the individual, including contact with a COVID-19 patient, smoking,
and hookah usage, among others.
2. COVID-19
Anxiety Scale (CDAS): This questionnaire was prepared and validated to
measure anxiety during the Corona era in Iran and has 18 items and 2 components
(factors) regarding anxiety. Items 1 to 9 measure psychological symptoms and
items 10 to 18 measure physical symptoms. The instrument is rated on a 4-degree
Likert scale (never = 0, sometimes = 1, most of the time = 2, and always = 3).
Therefore, the highest and lowest scores that respondents get in this
questionnaire are between 0 and 54. High scores indicate a high level of
anxiety in individuals. The total CDAS score was divided into 0–16 (mild),
17–29 (moderate), and 30–54 (severe). The reliability of this tool was obtained
using Cronbach’s alpha method for the cause of psychological symptoms (0.879)
and physical symptoms (0.861) of the total questionnaire (0.919) (39).
3.
Cohen's Perceived Stress Scale (PSS): 14-item version was used in this research. This scale is a
self-report tool consisting of 14 items that was developed by Cohen, Kamarck & and Mermelstein in 1983 in order to know how
individuals evaluate their difficult and exhausting experiences. In this scale,
individuals are asked to indicate on a five-point scale from 0 (never) to 4
(very much) how they often felt during the last 10 weeks. In this scale, after
reverse scoring the items 4, 5, 6, 7, 9, 10, and 13, a total score is obtained
by summing up the scores of all items for each person. On this scale, the
minimum and maximum scores are 0 to 56. The higher the score, the higher the
score. It means more perceived stress. In the study of Cohen et al. (1983), the
internal consistency coefficients for each of the subscales and the overall
score were between 0.84 and 0.86 (40). This
questionnaire was developed in Iran by Safaei and Shokri. , with the
translation and construct validity and convergent validity being confirmed.
Furthermore, the reliability of the survey was assessed and found to be
appropriate, with a value of 0.84 (41).
"4.
"Endler" and "Parker" Coping Strategies Questionnaire: The Coping
Strategies Questionnaire developed by Endler and Parker (1990) is comprised of
45 items that utilize the Likert method to determine responses ranging from
never (1) to always (5). The questionnaire is divided into three main areas of
coping behaviors, with each area containing 15 questions. These areas include
problem-focused coping, emotion-focused coping, and avoidant coping.
Problem-focused coping involves actively managing and solving the problem,
while emotion-focused coping focuses on emotional responses to the problem, and
avoidant coping involves running away from the problem. The scoring system for
this questionnaire is based on a 5-point Likert scale, with a maximum score of
5 and a minimum score of 1 for each subject. The score for each of the three
coping behaviors ranges from 15 to 75, with the behavior that receives the
highest score being considered the person's primary coping strategy. The total
score for the coping strategy ranges from 45 to 225 (42). Qureshi Rad et al. conducted the validation of this scale,
yielding a correlation coefficient of 0.84 and Cronbach's alpha of 0.83 for the
overall scale. Additionally, the subscales of problem-focused, emotion-focused,
avoidance, and social orientation demonstrated correlation coefficients of
0.86, 0.81, 0.79, and 0.69, respectively. The coping strategy in this study was
operationally defined as the total score obtained by individuals participating
in the study, based on their responses to the Andler and Parker coping
strategies questionnaire (43).
Data
analysis
In
this research, a total of 256 pregnant women were selected to participate by
completing questionnaires. However, three individuals declined to continue
their cooperation, resulting in a final sample size of 253 participants. Among
the remaining participants, 23 reported having an underlying disease, and nine
experienced significant stressful events within the past six months. These
individuals were excluded from the study, leaving a final analysis sample of
221 pregnant women. For data analysis, the researchers utilized SPSS-22
software. Descriptive statistics methods were employed to analyze the data,
including the use of frequency and percentage distribution tables for
qualitative variables. Additionally, quantitative variables were analyzed using
measures such as standard deviation, average, minimum, and maximum. To examine
the relationship between variables, Spearman's correlation coefficient tests
were conducted. Furthermore, to account for any confounding factors, the
researchers employed the multivariable linear regression method. The
significance level for all tests was set at 5%.
Results
Table
1 presents the demographic characteristics information of the participants.
Based on the data provided, the average age of pregnant women was 30.96 years,
with a standard deviation of 11.64. The age range varied from 18 to 44 years.
The gestational age ranged from 8 to 39 weeks. The number of pregnancies for
women ranged from 1 to 5, and the average gestational age was 26.62 with a
standard deviation of 8.87. A majority of the women (57.5%) held a diploma,
while 86% were housewives. Additionally, 67.4% of the participants had an
average household income between 2 and 5 million Tomans (Table 1).
Table 1. Participants’ demographic and
obstetrics characteristics (Frequency distribution of quantitative and
qualitative variables).
|
variables |
M±SD |
Maximum-minimum |
|
Age |
30.96±11.64 |
18-14 |
|
Gravida |
1.95±1.21 |
1-5 |
|
number of children |
0.57±0.75 |
0-3 |
|
Number of abortions |
0.35±0.75 |
0-5 |
|
Gestational age (weeks) |
26.62±8.87 |
8-39 |
|
variables |
|
Frequency(%) |
|
Mother’s Educational status |
|
|
|
Secondary school |
|
33(14.9) |
|
Diploma |
|
127(57.5) |
|
University |
|
61(27.6) |
|
Mother’s Employment status |
|
|
|
Housewife |
|
190(86) |
|
Self-employed |
|
12(5.4) |
|
Employed |
|
19(8.6) |
|
Spouse’s Educational status |
|
|
|
Secondary school |
|
42(19) |
|
Diploma |
|
119(53.8) |
|
University |
|
60(27.2) |
|
Spouse’s Employment status |
|
|
|
Self-employed |
|
147(66.5) |
|
Worker |
|
35(15.8) |
|
Employed |
|
30(13.6) |
|
Farmer |
|
9(4.1) |
|
Income |
|
|
|
≥ 20000000 rail |
|
36(16.3) |
|
20000000-50000000 rail |
|
149(67.4) |
|
≥50000000 rail |
|
36(16.3) |
The
mean (standard deviation) of the anxiety score and perceived stress score were
(16.57±7.16) and (31.06±8.64), respectively. The mean (standard deviation)
score of Problem-focused strategy,
Emotional-focused strategy, and avoidant coping strategy were (49.95±9.32),
(44.53±12.41) and (43.06±8.99) respectively. The minimum and maximum anxiety
score was 5-44, and the minimum and maximum perceived stress score was 13-56.
In addition, the minimum and maximum score of the total coping strategy was
59-192, the minimum and maximum score of the Problem-focused strategy was
21-70, the Emotional-focused strategy was 17-67, and the Avoidant coping
strategy was 21-68 (Table 2).
Table 2. Mean and standard deviation of
different dimensions of anxiety, perceived stress and adopted coping
strategies.
|
Variable |
kurtosis |
Skewness |
SD |
mean |
Min-max |
|
anxiety |
1.222 |
1.009 |
7.16 |
16.57 |
5-44 |
|
Perceived Stress |
-0.239 |
0.191 |
8.64 |
31.06 |
13-56 |
|
coping strategy |
0.111 |
-0.105 |
21.36 |
137.55 |
59-192 |
|
Problem-focused strategy |
-0.375 |
-0.169 |
9.32 |
49.95 |
21-70 |
|
Emotional-focused strategy |
-0.869 |
-0.142 |
12.41 |
44.53 |
17-67 |
|
Avoidant coping strategy |
0.176 |
0.320 |
8.99 |
43.06 |
21-68 |
Initial findings additionally indicated that 118 individuals
(60.6%) experienced mild anxiety, while 89 participants (40.3%) reported
moderate anxiety, and 14 individuals (6.3%) suffered from severe anxiety as a
result of the COVID-19 pandemic. Moreover, the assessment of perceived stress
revealed that 134 pregnant women (60.6%) exhibited elevated levels of stress.
In terms of coping strategies, 121 individuals (54.8%) employed problem-focused
coping, 79 individuals (35.7%) utilized emotion-focused coping, and 21
individuals (9.5%) resorted to avoidance coping (Table 3).
Table 3. Frequency of anxiety, perceived stress and stress and adopted
coping strategies.
|
% |
Frequency |
Level |
Variable |
|
|
|
|
Anxiety |
|
53.4% |
118 |
mild |
|
|
40.3% |
89 |
moderate |
|
|
6.3% |
14 |
severe |
|
|
|
|
|
Perceived
stress |
|
39.4% |
87 |
low |
|
|
60.6% |
134 |
high |
|
|
Coping
strategy |
|||
|
54.8% |
121 |
|
Problem-focused
strategies |
|
35.7% |
79 |
|
emotional-focused
strategies |
|
9.5% |
21 |
|
Avoidance
strategies |
The results show that there is a direct and significant linear
correlation between anxiety and the adopted coping strategies (r=0.263); also
the perceived stress and the adopted coping strategies (r=0.309)
(P-value=0.001>) in Meanwhile, there is a direct and significant linear
correlation between anxiety and emotion-focused coping strategy (r=0.413) and
between perceived stress and emotion-focused coping strategy (r=0.408)
(P-value=0.001). However, there is a direct linear correlation between anxiety
with avoidance coping strategy (r=0.183) (P-value=0.006) and between perceived
stress with avoidance coping strategy (r=0.169) (P-value=0.012). Also, there is
no direct and significant linear correlation between anxiety with
problem-focused strategies (r=-0.119) (P-value=0.078) and There is no direct
and significant linear correlation between perceived stress and problem-focused
strategies (r=-0.008) (P-value=0.906) (Table 4).
Table 4. Correlation between anxiety and perceived stress with adopted
coping strategies.
|
Avoidance strategies |
emotional-focused strategies |
Problem-focused strategies |
coping strategy |
Statistical tests |
|
|
|
|
|
Anxiety |
|
0.183 |
0.413 |
-0.119 |
0.263 |
Spearman
correlation coefficient |
|
0.006 |
0.001> |
0.078 |
0001> |
P-value |
|
|
|
|
|
Perceived
stress |
|
0.169 |
0.408 |
-0.008 |
0.309 |
Spearman
correlation coefficient |
|
0.012 |
0.001> |
0.906 |
0.001> |
P-value |
The results of linear regression show that with the increase of
each unit in the emotion- focused strategy score, the anxiety score increases
by 0.4 or 40%, provided that other factors are constant. In the variable of
anxiety, the squared multiple correlation coefficient (R2 variable coefficient)
equal to 0.167 shows that the predicting variables of triple strategies predict
16.7% of the variance of anxiety scores of pregnant women. Also, the results of
multiple linear regression show that with the increase of each unit in the
emotion-focused strategy score, the perceived stress score increases by 0.39 or
39%, provided that other factors are constant. In the stress variable, the
squared multiple correlation coefficient (R2 variable coefficient) equal to
0.147 shows that the predicting variables of the triple strategies predict
14.7% of the variance of the stress scores of pregnant women (Table 5).