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Research Article | DOI: https://doi.org/10.31579/2578-8965/167
Department of Midwifery, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia.
*Corresponding Author: Wogene Daro Kabale, Department of Midwifery, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia.
Citation: Wogene D. Kabale, Gemechu G. Bekele, Ephrem Y. Roga, Dajane N. Gonfa, Amare T. Yami, (2023), Perceived Stress and Associated Factors Among Pregnant Women in Western Ethiopia: Community Based Cross-Sectional Study, 2021, J. Obstetrics Gynecology and Reproductive Sciences, 7(3) DOI:10.31579/2578-8965/167
Copyright: © 2023, Wogene Daro Kabale. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 20 April 2023 | Accepted: 19 May 2023 | Published: 30 May 2023
Keywords: perceived stress; pregnancy; mental health; psychosocial health; west Shewa; ethiopia
Background: Ethiopian health care guidelines did not include antenatal perceived stress as a component of routine antenatal care, and this results in under-diagnosis of antenatal perceived stress during routine antenatal care follow-up. As a result, the purpose of this study to assess the prevalence of perceived stress and associated factors among pregnant women in the western Ethiopia.
Methods: A community-based cross-sectional study was conducted among 451 pregnant women in West Shewa Zone, Oromia Region, Ethiopia. From September 20, 2021, to October 19, 2021, Pregnant women were recruited using cluster sampling techniques. Data was collected by using a standardized questionnaire that had been pre-tested. The data were entered into Epi data version 4.6 and then exported to SPSS version 26. Bivariate and multivariate logistic regression analyses were used to identify significantly associated factors.
Result: The prevalence of perceived stress during pregnancy was 21.2% at 95% CI (20.1,23). Unplanned pregnancies (AOR: 5.43; CI 2.61-10.77), early ANC booking (AOR: 3.02 CI; 1.66-5.48) and obstetric complications during the current and previous pregnancies (AOR: 3.53CI; 1.9- 6.56) were significantly associated with perceived stress.
Conclusion: The prevalence of perceived stress during pregnancy was higher, indicating a need to screen perceived stress and its predictors in routine antenatal care. Strengthening the counseling service and increasing access and availability of modern contraceptive methods may reduce the rates of unplanned pregnancies. This, in turn, plays a significant role in alleviating perceived stress in Ethiopia.
Stress is the response of human physiology to a demanding situation [1]. Perceived stress (PS) is the person's perceptions level of stress at a specific moment in time or over a certain length of time in response to problems or difficulties [2]. Perceived stress during pregnancy is inability pregnant women to cope with demands and worries, resulting in the experience of stress that manifests both behaviorally and physiologically [3].
Pregnant women have a positive outlook on their outcomes, but it is a time of increased vulnerability to stress due to changes in hormonal levels [4], and pregnancy-related stressors especially in developing countries because of the high level of stressors like poverty, unwanted pregnancy, high parity, and pregnancy-related complications [5]. Perceived stress is the cause of morbidity and mortality worldwide. It is one of the most common mental health conditions in the general population, with an estimated prevalence of 35% in the adult population [6].
Women are more stressed and affected by family responsibilities than men; additionally, pregnancy has been identified as a vulnerable period with an increased risk of psychosocial symptoms [7]. Stress is a common part of life, but when it occurs during pregnancy, it can go beyond what is expected and cause problems. High levels of stress during pregnancy may affect the mother's ability to do daily activities, including sleeping, eating, and feeling [8, 9].
According to different literature reports, the prevalence of PS during pregnancy in developed countries ranges from 10%-33.4% [10, 11], while in developing countries, including Ethiopia, it ranges between 11.6-65.4% [1, 12-14]. As of the study conducted in Canada, Arbaminch Town, Iran, Saudi Arabia, Ghana, and Thailand, the prevalence of PS during pregnancy was 12%, 23.1%, 11.5%, 33.4%, 28.6%, and 23.6%, respectively [4, 5, 10, 11, 15, 16].
Stress has a significant impact on the pregnancy's course and outcomes; it also has an impact on maternal, fetal, neonatal, and adolescent wellbeing [17]. Evidence suggests that stress during pregnancy increases the risk of pre-term birth (PTB) [18], alters fetal body mass index (BMI) [19], very low birth weight (VLBW) [20], and pre-term delivery (PTD) [21], lower iron storage at birth, and the likelihood of low plasma ferritin levels at 1 year of age [22]. and it also increases the levels of pregnancy-induced hypertension [23], hyperemesis gravidarum [1], and spontaneous abortion [24].
The American college of obstetrics and gynecology (ACOG) 2000 census recommended prenatal screening and intervention for psychosocial risk factors, including stress, for all pregnant women during their ante-natal care (ANC) follow-up [25]. The majority of Ethiopian pregnant women receive prenatal care as recommended by the World Health Organization. However, current prenatal care does not employ screening tools to detect women experiencing high levels of stress or does not assess pregnant mothers' emotional status [25].
To avoid the detrimental effects of stress during pregnancy on both the fetus and the mother, prenatal care providers must screen for and give appropriate care during the antenatal period [18].
Divorce, separation from spouse, physical or psychological trauma from family, multigravida, gestational age of less than 12 weeks, obstetric and medical complications during pregnancy, stressful life events, and family conflict are just a few of the factors that can increase or decrease the perception of stress during pregnancy, which is amplified by hormonal changes [11, 15, 16].
To the investigator's knowledge, there are limited studies conducted in Ethiopia whose results lack consistency and some psychosocial factors like a stressful life event. Furthermore, in the study area, the prevalence and contributing factors of PS among antenatal women were not studied. Therefore, this study assessed the prevalence and associated factors of perceived stress during pregnancy.
Study Setting
The study was conducted from September 20 to October 19, 2021, in the West Shewa zone, Oromia regional state, Ethiopia. The West Shewa zone has a total of 23 woredas (districts), including Ambo town, the capital of the zone. The projected population of the West Shewa zone is about 2.8 million (1.4 million men and 1.4 million women). During the study period, there were 26, 7399 pregnant women, of whom 17, 9160 were in the 2nd and 3rd trimesters of pregnancy. One teaching referral hospital, three general hospitals, four basic hospitals, 100 health centers, and 447 health posts make up the zone's health system, which covers 93% of potential health care coverage. The majority of the population is Protestant, with 53.43% stating that they adhered to this creed, while 37.1% practiced Ethiopian Orthodox Christianity, and 8.2% identified as Muslim. A community-based cross-sectional study was conducted in the West Shewa zone.
Study population
All pregnant women found in the selected district during the study period were included in the study.
Inclusion criteria and Exclusion criteria
All pregnant women who were permanent residents of the area and that they are willing to participate were included and those with known psychiatric illness and seriously sick women were excluded.
Sample size determination and procedure
The sample size was determined by using the single population proportion formula by considering the following statistical assumptions: The prevalence of PS among pregnant women attending ANC at the governmental health institution in Arba Minch town was 23.1% (15). A cluster sampling technique was employed to select three woredas, such as Toke Kutaye, Ambo, and Bako out of 23 woredas. Health extension workers of each woreda listed pregnant mothers using the non-identifying registration code. We have used this registration as a sampling frame to recruit the study participants. Finally, a total of 451 pregnant mothers who were in the second or third trimester of pregnancy were employed in the study by using a systematic random sampling. The value of "K" was calculated by using the list of pregnant women obtained from the registration book of health extension workers from respective woredas. Then for K for Toke Kutaye Woreda, there were 3590 registered women (K = 3590/451 = 7.960); for K for Ambo woreda, there were 3401 registered women (K = 3401/451 = 7.54); and for K for Bako woreda, there were 3551 registered women (K = 7.87). Hence, the sample interval was 7.9, 7.5, and 7.8 for each woreda, which approximated to 8. Therefore, individuals were chosen at regular intervals (every eight), and the first study participant was selected by lottery from the one to eight and three were selected randomly.
Data Collection tool and procedure
The data was collected using a structured and pre-tested questionnaire. To ensure consistency, the questionnaire was translated from English to Afaan Oromo and then back from Afaan Oromo to English. The data was collected using an Afaan Oromo version of the questionnaire. The data gathering method was a face-to-face interview. For data collection, six bachelor's degrees in nursing psychiatry students were selected. A questionnaire took an average of 20-30 minutes to complete. The mothers were informed of all aspects of the study by the interviewers. The women were urged to be themselves and advised that their responses would be kept private and that no information would be shared with anyone other than the investigator. Following that, a woman who agreed to participate and completed the informed permission form was interviewed in a calm and comfortable environment. The data collection process was overseen and double-checked for accuracy and completeness. The supervisor and primary investigator examined and cross-checked questionnaires for completeness, accuracy, and consistency after each day.
The interview consists:
Demographic characteristics: demographic data, which provided baseline information, was obtained from the participants, including age, ethnicity, religion, education, occupation, marital status, wealth index, and residency.
Obstetrics and gynecological 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, ANC counselling, and other illnesses was obtained from participants.
Perceived stress: The 10-item Likert-type Perceived Stress Scale (PSS) was used to assess perceived stress caused by perceptions of difficulty in controlling or coping with life events in the previous month. 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 cutoff point 21 and higher scores indicating perceived higher stress [11].
Social support: It was measured by a 6-item, self-reported, 5-point Likert scale. The total score ranged from 1 to 30. The score was summed and classified as having high maternal social support (for scores 24–30), medium social support (18–23), and low social support (<17>
Intimate partner violence: consists of five questions to determine the status of intimate partner violence. The questionnaire was developed from a WHO multi-country study on violence against women, and if any questions on the screen were answered yes, the participant was considered positive for abuse [26].
Stressful life event: measured by 13-item questions, the woman was asked to indicate whether she had personally experienced any serious life events in the last six months, and she was considered to have experienced a stressful life event if she answered yes to any one of the questions [27].
Data Quality Controls
The structured questionnaire was pre-tested on 5% of pregnant women at Oromia’s Adeya Berga Woreda. Additionally, the principal investigator provided data collectors with a two-day training to raise awareness about the data that would be collected, the importance of timely collection, and data management, as well as the basic technique of data collection, approaches, and the issue of confidentiality and privacy. The study participants were given a thorough description of the study's goal and method to get informed consent and trustworthy data. Furthermore, supervisors monitored the data collectors daily. The supervisors and primary investigator verified the completed questionnaire for completeness and consistency daily. Finally, the completed questionnaire was double-checked to confirm that all data had been correctly obtained and recorded
Data were coded and entered into Epidata Version 4.6 before being exported and analyzed in SPSS Version 26. The binary logistic regression employed to find characteristics linked to the perceived stress during pregnancy. In a multivariate logistic regression model, variables with P<0>
Socio-demographic characteristics of the study participants
Out of the total 451 pregnant women planned for the study, 438 were enrolled in the study making a response rate of 97.1%. The mean (± standard deviation) of the respondent's age was 26.92(±5.13), with a range of 15_40 years. Two hundred and sixty-seven of the study participants (60.6%) were in the age group of 20-29 years. Four hundred and thirty-one of the respondents (98.4%) were married and 363(82.9%) housewives in occupation. Half of the pregnant women 225(56.9%) attended primary school. Regarding the occupation of husbands 345(78.8%) were farmers and 258(58.9%) attended primary school. Almost all 431(98.4 %) pregnant women were living with their husbands and 176(40.2%) of the respondents were grouped under moderate wealth quintiles (Table 1).
| Variable | Category | Frequency | Percentage |
| Age | <19> | 38 | 8.7 |
| 20-24 | 110 | 25.1 | |
| 25-29 | 157 | 35.8 | |
| 30-34 | 96 | 21.9 | |
| >35 | 37 | 8.5 | |
| Education of mother | Can’t read and write | 55 | 12.5 |
| Can read and write | 134 | 30.6 | |
| Primary school | 225 | 51.4 | |
| Secondary school and above | 24 | 5.5 | |
| Occupation of mother | Housewife | 363 | 82.9 |
| Merchant | 54 | 12.3 | |
| Other* | 21 | 4.8 | |
| Marital status | Married | 431 | 98.4 |
| Cohabitant | 7 | 1.6 | |
Partner education
| Can't read and write | 47 | 10.7 |
| Can read and write | 101 | 23.1 | |
| Primary school | 258 | 58.9 | |
| Secondary school and above | 32 | 7.3 | |
| Partner occupation | Farmer | 345 | 78.8 |
| Merchant | 68 | 15.5 | |
| Government employed | 9 | 2.0 | |
| Other** | 16 | 3.7 | |
| Living arrangement | With husband | 431 | 98.4 |
| Alone | 7 | 1.6 | |
| Wealth index | Very poor | 41 | 9.4 |
| Poor | 120 | 27.4 | |
| Medium | 176 | 40.2 | |
| Rich | 22 | 5.0 | |
| Very rich | 79 | 18.0 |
NB ⃰-government employed/student/daily laborer, **- student/daily laborer/private employed
Table 1: Sociodemographic characteristics of perceived stress among pregnant women in West Shewa, Oromia regional state, Ethiopia. 2021(n=451)
Obstetric characteristics of the respondents
Of the total study participants, 323(73.7%) were multigravida and 389(88.8%) of the current pregnancy were planned. Two hundred and seventy-four (62.6%) of the study participants were in their second trimester of pregnancy. At the time of the interview, three hundred and seventy-nine participants (86.5%) had antenatal care for this pregnancy. Among those pregnant women who attended ANC, 143(32.6%) had visited one time and for 361(82.4%) pregnant women counseling was provided. Regarding their timing for ANC, one hundred twenty-one (27.6%) respondents visited health facilities for the first ANC follow-up before or at 16 weeks of gestational age. Twenty and eight (6.4%) of the respondents had a history of abortion, and 8(1.8%) had a history of multiple gestations. During the current and previous pregnancies, 374(85.4%) of pregnant women did not face obstetric complications. Four and twenty-nine (97.9%) of pregnant women had no history of chronic medical illnesses (Tabl
| Variable | Categories | Frequency | Percentage |
| Gravidity | Prim-gravida | 87 | 19.9 |
| Multi-gravid | 323 | 73.7 | |
| Grand multi-gravid | 28 | 6.4 | |
| Parity | Nulli-parious | 94 | 21.5 |
| Primi-parious | 103 | 23.5 | |
| Multi-parious | 241 | 55.0 | |
| Pregnancy status | Planned | 389 | 88.8 |
| Unplanned | 49 | 11.2 | |
| Gestational age | First trimester | 19 | 4.3 |
| Second trimester | 274 | 62.6 | |
| Third trimester | 145 | 33.1 | |
| Antenatal care follows up | Yes | 379 | 86.5 |
| No | 59 | 13.5 | |
| Number of Antenatal cares follow up | One time | 143 | 37.7 |
| Two times | 133 | 35.1 | |
| Three times | 80 | 21.1 | |
| Four and above times | 23 | 6.1 | |
| Counseling during pregnancy | Yes | 361 | 95.3 |
| No | 18 | 4.7 | |
| Antenatal care initiation | Had no Antenatal care follow up | 59 | 13.5 |
| Before 16 weeks of Gestation | 121 | 27.6 | |
| After 16 weeks of gestation | 258 | 58.9 | |
| Abortion history | No | 410 | 93.6 |
| Yes | 28 | 6.4 | |
| Multiple gestation | Yes | 8 | 1.8 |
| No | 430 | 98.2 | |
| Obstetric complication | Yes | 64 | 14.6 |
| No | 374 | 85.4 | |
| Chronic medical illness | Yes | 9 | 2.1 |
| No | 429 | 97.9 |
Table 2: Obstetric characteristics of pregnant women in West Shewa, Oromia regional state, Ethiopia, 2021, (n=451)
Perceived stress during pregnancy
Among 438 study participants, the prevalence of perceived stress was 21.2% with a range of 20.1-23 at 95% CI (Figure 1).
Figure 1: Prevalence of perceived stress among pregnant women in West Shewa, Oromia regional state, Ethiopia. 2021(n=451)
Factors associated with perceived stress during pregnancy
In the bivariate analysis, the gravidity of the women, the status of pregnancy, time of ANC initiation, having previous and current obstetric complications during pregnancy, having concern towards partner worries, abuse during pregnancy, and experiencing stressful life events in the last six months were variables that had a p-value less than 0.25.
In the multivariate analysis status of pregnancy, time of ANC initiation, and having previous and current obstetric complications were associated with perceived stress among pregnant women in West Shewa Zone at a p-value of < 0>
Table 3: Bi-variable and multivariable logistic regression model for factors associated with perceived stress during pregnancy in West Shewa, Oromia regional state, Ethiopia, 2021(=451).
It was observed that mothers who had unplanned pregnancies were 5.39 times more likely to have had perceived stress as compared to mothers who did not have unplanned pregnancies (AOR=5.39; 95%CI: 2.66, 10.92).
After adjusting other variables odds of developing perceived stress were 3.14 times higher among pregnant women who initiate their antenatal care follow-up before or at sixteen weeks as compared to those initiated after sixteen weeks of gestation (AOR=3.14; 95%CI: 1.8, 5.48).
In addition, the odds of having perceived stress among pregnant women who ever had obstetric complications during pregnancies were 3.22 times higher than those women who did not have obstetric complications (AOR=3.22; 95%CI: 1.73, 6.01).
The current study indicated that the prevalence of perceived stress among pregnant mothers was found to be 21.2
The prevalence of perceived stress during pregnancy in Ethiopia is high. Being unplanned pregnancy, early initiation of antenatal care follow-up, and obstetric complications during the current and previous pregnancy are the main predictors of perceived stress during pregnancy.
Screening of perceived stress during antenatal care follow was one of the recommendations of the American college of obstetrics and gynecology and based on our result we recommended that for West Shewa health office by collaborating with other regional health offices and other stack-holder should organize conferences to create awareness on perceived stress, the importance, and benefit of early ANC booking as well as family planning to the community in order to avert the level of high perceived stress. For researchers to conduct further research through the qualitative method and other research designs having a longer period.
Ethical approval and consent to participate
Hawassa University, College of Health and Medical Sciences, Institutional Review Board provided ethical clearance (IRB) with Ref.No: IRB/279/13. Hawassa University wrote to West Shewa Zone letter requesting permission and help. Permission was also obtained from the administrators of each Woredas(districts). The purpose of the study and their ability to decline was explained to all study participants. Before the distribution of the questionnaires, all study participants gave their informed, written, and signed consent. The respondents were assured that the information acquired from them would be kept confidential.
The datasets used or analyzed during the current study are available from the corresponding author upon request.
Funding
This research did not receive any grant from any funding agencies in the public, commercial or not-for-profit sectors.
Consent for publication
Not applicable
Conflicts of interest
The authors declare that they have no potential conflict of interest.
Acknowledgment
We are grateful to Hawassa University, College of Medicine and Health Sciences for enabling us to conduct this study. The West Shewa zonal Health Office, study participants, data collectors, and supervisors have all been tremendously helpful.
WDK was involved in the project's conception and design. EYR assisted with data curation, and supervision, ATY engaged in investigation, and project administration, and WDK participated in writing up, review & editing the manuscript. All authors participated in funding acquisition, resource mobilization, and validation. WDK and GGB were involved in methodology, and software, and handled data analysis, interpretation, and writing the original draft. In addition, DNG contributed to the visualization. All of the authors agreed to submit to the current journal and gave final approval of the published version; they also solely agreed.
Abbreviations
ANC (Antenatal Care)
ACOG (American College of Obstetrics and Gynecology)
AOR (Adjusted Odd Ratio)
BMI (Body Mass Index)
CI (Confidence Interval)
COR (Crude Odd Ratio)
PS (Perceived Stress)
PTB (PreTerm Birth)
PTD (PreTerm Delivery)
VLBW (Very Low Birth Weight)
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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
