Depression,anxiety and stress among Pregnant women

Depression, Anxiety and stress among Pregnant Women

Chandrakant Jamadar

Asst.Professor

P.G.Studies in Psychology

Maharani Arts & Commerce College

J.L.B.Road,MYSORE,KARNATAKA-570005

INDIA

E-mail ID-mscbrain@gmail.com

ABSTRCT

The present study is aimed to study the depression, anxiety and stress among pregnant women. and to compare the depression, Anxiety and Stress during 1^st trimester and 2^nd trimester. Sample of the study consisted 30 pregnant women from the villages coming under Bageshpur Primary Health Center area of Arsikere taluk Hassan district. Their age ranged between 20 to 30 years. Respondents were belonging to low& middle socio-economic status. The personal data sheet prepared by the investigator and DASS scale by Lovibond (1995) were used. Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean ± SD (Min-Max) and results on categorical measurements are presented in Number (%). Significance is assessed at 5 % level of significance. Student t test (two tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group. Effect size has been computed and Pearson correlation between variables is performed. The result indicates that correlation coefficient was strongly significant at 0.001 level between depression & anxiety, depression & stress, anxiety& stress during both the trimesters. There is significant decrease in depression during 2^nd trimester compared to 1^st trimester, where as highly significant decrease in anxiety & stress during 2^nd trimester compared to 1^st trimester.

Key words: Pregnant women, Trimester, Depression, Anxiety & Stress

Depression, Anxiety and stress among Pregnant Women

Introduction

Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the womb of a female. Human pregnancy is the most studied of all mammalian pregnancies. Childbirth usually occurs about 38 weeks after conception; in women who have a menstrual cycle length of four weeks, this is approximately 40 weeks from the last normal menstrual period (LNMP). The World Health Organization defines normal term for delivery as between 37 weeks and 42 weeks. Although pregnancy begins with implantation, the process leading to pregnancy occurs earlier as the result of the female gamete, or oocyte, merging with the male gamete, spermatozoon. In medicine this process is referred to as fertilization, in lay terms, it is more commonly known as "conception". After the point of fertilization, the fused product of the female and male gamete is referred to as a zygote or fertilized egg. The fusion of male and female gametes usually occurs following the act of sexual intercourse resulting in spontaneous pregnancy. The expected date of delivery (EDD) is 40 weeks counting from the first day of the last menstrual period (LMP), and birth usually occurs between 37 and 42 weeks. There is a standard deviation of 8-9 days surrounding due dates calculated with even the most accurate methods. This means that fewer than 5% of births occur at exactly 40 weeks; 50% of births are within a week of this duration, and about 80% are within 2 weeks

Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, but these distinctions are useful in describing the changes that take place over time. The first 12 weeks of pregnancy are considered to make up the first trimester. It is also called as embryonic stage. In medicine, pregnancy is often defined as beginning when the developing embryo becomes implanted into the endometrial lining of a woman's uterus. In some cases where complications may have arisen, the fertilized egg might implant itself in the fallopian tubes, the cervix, the ovary or in the abdomen, causing an ectopic pregnancy. In the case of an ectopic pregnancy, there is no way for the pregnancy to progress normally. If left untreated, it can cause harm and possibly death for the mother when a rupture occurs. Sometimes it will go away on its own, but otherwise a surgical procedure or medicine is given to remove the tubal pregnancy, since there is no way of the pregnancy being able to continue safely. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding at implantation. Some women will also experience cramping during their first trimester. Many physiological changes in herself & her sociological status like sudden stop of menstrual periods especially in unplanned pregnancy, feeling of morning sickness ,fear about miscarriage ,varied reactions of family members & many more make oneself to feel anxious.

Weeks13 to 28 of the pregnancy are called the second trimester. At this point, the fetal stage begins. At the beginning of the fetal stage, the risk of miscarriage decreases sharply, all major structures including the head, brain, hands, feet, and other organs are present, and they continue to grow and develop. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. In the 20th week, the uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy. Although the fetus begins to move and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as “quickening” can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproductive organs distinguish the fetus as male or female. The heart can be seen beating via sonograph; the fetus bends the head, and also makes general movements and startles that involve the whole body. Some fingerprint formation occurs from the beginning of the fetal stage. As risk of miscarriage decreases & morning sickness problem subsides and more than that now woman can feel her baby, its movements this, compared to the 1^st trimester make woman feel somewhat relaxed & happy.

Rest of the weeks make third trimester -Final weight gain takes place, which is the most weight gain throughout the pregnancy.

Although pregnancy is often portrayed as a time of great joy, that's not the reality for all women. At least one in ten pregnant women suffers from bouts of depression. For years, experts mistakenly believed that pregnancy hormones protected against depression, leaving women more vulnerable to the illness only after the baby was born and their hormone levels plunged. They now believe that the rapid increase in hormone levels at the start of pregnancy can disrupt brain chemistry and lead to depression. Hormonal changes can also make you feel more anxious than usual. Anxiety is another condition that can and should be treated during pregnancy. Depression and anxiety may go undiagnosed because women often dismiss their feelings, chalking them up to the temporary moodiness that often accompanies pregnancy. So one should not be shy about letting their doctor or midwife know if they feel low. Pregnant woman emotional health is every bit as important as her physical health. And in fact, it can affect her physical health.

Van den Bergh BR, Mulder EJ, Mennes M, Glover V,(2005),(1) in Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review, identified a direct link between antenatal maternal mood and fetal behaviour, as observed by ultrasound from 27 to 28 weeks of gestation onwards, is well established. Moreover, 14 independent prospective studies have shown a link between antenatal maternal anxiety/stress and cognitive, behavioral, and emotional problems in the child. This link generally persisted after controlling for post-natal maternal mood and other relevant confounders in the pre- and post-natal periods. Although some inconsistencies remain, the results in general support a fetal programming hypothesis. Several gestational ages have been reported to be vulnerable to the long-term effects of antenatal anxiety/stress and different mechanisms are likely to operate at different stages. Possible underlying mechanisms are just starting to be explored. Cortisol appears to cross the placenta and thus may affect the fetus and disturb ongoing developmental processes. The development of the HPA-axis, limbic system, and the prefrontal cortex are likely to be affected by antenatal maternal stress and anxiety. The magnitude of the long-term effects of antenatal maternal anxiety/stress on the child is substantial. Programs to reduce maternal stress in pregnancy are therefore warranted.

O'Brien L, Schachtschneider AM, Koren G, Walker JH, Einarson A.( 2007),(2) With the objectives: To determine the effectiveness of maintaining antidepressants during pregnancy, as measured by changes in symptoms of depression, anxiety, irritability, and stress following reassuring evidence-based counseling carried out a Longitudinal study of depression, anxiety, irritability, and stress in pregnancy following evidence-based counseling on the use of antidepressants. Depressed women who were pregnant and taking antidepressants, and who called the Motherisk program for advice, participated in a study that involved reassuring evidence-based counseling on the risk of antidepressants in pregnancy, followed by four telephone interviews: one in each trimester and one in the postpartum period. Depression, anxiety, irritability, and stress scales were completed at each call .Of the 58 women who enrolled in the study, 38 completed 75% of the follow-ups. Eight women (14%) discontinued their medication during the study. Depression scores were highest at enrollment in the first trimester and decreased as pregnancy progressed. When data from all women, regardless of dose adjustments, were analyzed, no statistically significant differences were seen between depression scores at any time point; mean depression scores were below the cut off for depression throughout the study period. Irritability, anxiety, and stress scores were not found to be statistically different at any time point during the study. Evidence-based reassurance and continuous antidepressant pharmacotherapy during gestation can provide pregnant women with effective symptom control for their depression. Women should consult their healthcare provider to ensure that they are being treated effectively; a risk/benefit assessment should be conducted on a case-by-case basis.

Rozina Karmaliani, Nargis Asad , Carla M. Bann , Nancy Moss , Elizabeth M. Mcclure, Omrana Pasha , Linda L. Wright, Robert L. Goldenberg ,(2009)(3)in a study of Prevalence of Anxiety, Depression and Associated Factors Among Pregnant Women of Hyderabad, Pakistan, aimed to determine the prevalence of anxiety and depression and evaluate associated factors, including domestic violence, among pregnant women in an urban community in Pakistan. All pregnant women living in identified areas of Hyderabad, Pakistan were screened by government health workers for an observational study on maternal characteristics and pregnancy outcomes. Of these, 1,368 (76%) of eligible women were administered the validated Aga Khan University Anxiety Depression Scale at 20—26 weeks of gestation. Results showed that Eighteen per cent of the women were anxious and/or depressed. Psychological distress was associated with husband unemployment (p = 0.032), lower household wealth (p = 0.027), having 10 or more years of formal education ( p = 0.002), a first (p = 0.002) and an unwanted pregnancy ( p < 0.001). The strongest factors associated with depression/anxiety were physical/sexual and verbal abuse; 42% of women who were physically and/or sexually abused and 23% of those with verbal abuse had depression/anxiety compared to 8% of those who were not abused. They came to a conclusion that Anxiety and depression commonly occur during pregnancy in Pakistani women; rates are highest in women experiencing sexual/physical as well as verbal abuse, but they are also increased among women with unemployed spouses and those with lower household wealth. These results suggest that developing a screening and treatment programme for domestic violence and depression/anxiety during pregnancy may improve the mental health status of pregnant Pakistani women.

Parcells,D.A.(2010),(4)in a study Women's mental health nursing: depression, anxiety and stress during pregnancy. assessed maternal depression, anxiety and stress of 59 pregnant women (average age = 22 years) at 26–28 and 32–34 weeks of pregnancy. Measures included clinical interviews, maternal self-report and an estimate of the stress hormone cortisol from maternal saliva samples.The results indicated high incidences of prenatal depression, anxiety and stress across the third trimester. Therefore, the diagnosis of psychosocial conditions in women of childbearing age requires continued application of a caring nursing framework and open communication between patients, families and caregivers. Self-report measures may suffice in reaching a probable diagnosis, yet additional information may be extracted using a structured clinical interview for formal diagnosis.

Karmaliani R, Bann CM, Pirani F, Akhtar S, Bender RH, Goldenberg RL, Moss N.(2007)(5) while studying Diagnostic validity of two instruments for assessing anxiety and depression among pregnant women in Hyderabad, Pakistan, found out , 71 (36%) of the women were diagnosed with depression or anxiety or both. The objective of the study was to compare the diagnostic validity of two measures, the Aga Khan University Anxiety and Depression Scale (AKUADS) and the How I Feel scale, for assessing anxiety and depression among pregnant women in Pakistan. The sample included 200 pregnant women in Hyderabad, Pakistan. Using psychiatrist-administered Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) criteria.

Kaniz Gausia, Colleen Fisher, Mohammed Ali and Jacques Oosthuizen (2009),(6) Antenatal depression and suicidal ideation among rural Bangladeshi women: a community-based study, Aim of the study was to estimate the prevalence of depression during pregnancy and to identify potential contributory factors among rural Bangladeshi women, a community-based study was conducted during 2005 in Matlab sub-district, a rural area of eastern Bangladesh. Three hundred and sixty-one pregnant women were identified through an existing health and demographic surveillance system covering a population of 110,000 people. The women were interviewed at home at 34–35 weeks of pregnancy. Information on risk factors was collected through structured questionnaires, with the Bangla version of the Edinburgh Postnatal Depression Scale (EPDS-B) used to measure their psychological status. Both univariate analysis and multivariate logistic regression were applied using the SPSS 15.0 statistical software. The prevalence of depression at 34–35 weeks pregnancy was 33% (95% CI, 27.6–37.5). After adjustment in a multivariate logistic regression model, a history of being beaten by her husband either during or before the current pregnancy had the highest association with depression followed by having an unhelpful or unsupportive mother-in-law or husband, and family preference for a male child. Of the antenatally depressed women, 17 (14%) admitted to thoughts of self-harm during the pregnancy. This paper further explores the reasons why women have considered some form of self-harm during pregnancy. Depression during pregnancy is common among Bangladeshi women, with about a third being affected. The study highlights the need to allocate resources and develop strategies to address depression in pregnancy.

Problem: “The Effect Time (trimester) in depression, Anxiety and stress among Pregnant Women”.

Objectives:

1. To study the depression, anxiety and stress among pregnant women.

2. To compare the depression, Anxiety and Stress during 1^st trimester and 2^nd trimester.

Materials and methods:

Sample of the study consisted 30 pregnant women from the villages coming under Bageshpur Primary Health Center area of Arsikere taluk Hassan district. The random method was employed in the selection of the sample. The respondents were given assurance of confidentiality.

Tools:

Following tools were employed in the present study

1. Personal data sheet

2. DASS scale by Lovibond (1995) was used to measure Depression, Anxiety &Stress.

Personal data sheet: The socio demographic data for the present research was elicited using this personal data sheet. The researcher prepared this schedule himself. This is detailed schedule, which consists of provision to collect data on age, sex, income etc.

Depression Anxiety stress scale by Lovibond (DASS) (1995)

Internal consistency reliability coefficients for DASS-42 items, depression, anxiety stress subscales and full scale were found to be high with cronbach’s alphas of .89, .85, .81 and .95 respectively. For DASS-21, these values were .79,.71, .76 and .89.

Statistical Methods:

Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean ± SD (Min-Max) and results on categorical measurements are presented in Number (%). Significance is assessed at 5 % level of significance. Student t test (two tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group. Effect size has been computed and Pearson correlation between variables is performed. Student t test (two tailed, dependent) has been used to find the significance of study parameters on continuous scale with in each group. Effect size has been computed and Pearson correlation between variables is performed

1. Student t-test for paired comparisons

Definition: Used to compare means on the same or related subject over time or in differing circumstances.

Assumptions: The observed data are from the same subject or from a matched subject and are drawn from a population with a normal distribution.

Characteristics: Subjects are often tested in a before-after situation (across time, with some intervention occurring such as a diet), or subjects are paired such as with twins, or with subject as alike as possible.

Test: The paired t-test is actually a test that the differences between the two observations is 0. So, if D represents the difference between observations, the hypotheses are:

H_o: D = 0 (the difference between the two observations is 0)

H_a: D 0 (the difference is not 0)

The test statistic is t with n-1 degrees of freedom. If the p-value associated with t is low (< 0.05), there is evidence to reject the null hypothesis. Thus, you would have evidence that there is a difference in means across the paired observations.

, where ,

and di is the difference formed for each pair of observations

2.Effect Size

=

No effect (N)	d<0.20
Small effect (S)	0.20
Moderate effect (M)	0.50
Large effect (L)	0.80
Very large effect (VL)	d>1.20

3. t-test of a correlation coefficient

Objective: To investigate whether the difference between the sample correlation co-efficient and zero is statistically significant.

Limitations: It is assumed that the x & y values originates from a bivariate normal distribution and that relationship is linear. To test an assumed value of population co-efficient other than zero, refer to the Z-test for a correlation co-efficient.

is calculated and follows student t distribution with n-2 degrees of freedom.

4. Classification of Correlation Co-efficient (r)

Up to 0.1 Trivial Correlation

0.1-0.3 Small Correlation

0.3-0.5 Moderate Correlation

0.5-0.7 Large Correlation

0.7-0.9 V.Large Correlation

0.9- 1.0 Nearly Perfect correlation

1 Perfect correlation

5. Significant figures

+ Suggestive significance (P value: 0.05

* Moderately significant ( P value:0.01

£ 0.05)

** Strongly significant (P value : P£0.01)

Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1 ,Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.

Results and Discussion

The objectives of the present study are to find out the depression, anxiety and stress among pregnant women. & to compare the depression, Anxiety and Stress during 1^st trimester and 2^nd trimester. The data obtained from 30 pregnant women from the villages coming under Bageshpur Primary Health Center area of Arsikere taluk Hassan district. Relevant statistical techniques to test the objectives formulated for the study. The results were presented in the Tables.

They are in the age group of 20 to 30 years. Table 1 & Graph 1 shows that among 30 women under study 21(70%) of them are in age range between 20-25 years. And rest 9 (30%) are in age range between 26-30 years.

Table 2 & Graph 2 shows depression, anxiety and stress among pregnant women. during 1^st trimester and 2^nd trimester. The result indicates that correlation coefficient was strongly significant at 0.001 level between depression & anxiety, depression & stress, anxiety& stress during both the trimesters. Irrespective of the trimesters depression leads to anxiety & stress and vice versa.

Table 3& Graph 3 shows Levels of depression, Anxiety & stress at 1^st trimester and 2^nd trimester. Results indicated significant decrease in depression in 2^nd trimester compared to 1^st trimester, where as highly significant decrease in anxiety & stress in 2^nd trimester compared to 1^st trimester. Results also shows that stress is more during both the trimester as compared to depression & anxiety. The scores are as follows in the 1^st trimester mean and SD of depression is 18.67±8.59 & 18.67±8.59 in 2^nd trimester, difference is 5.30 with the ‘p’ value of 0.023* &effect size is 0.60(moderate). 1^st trimester mean and SD of anxiety is 20.87±9.07 & 13.90±6.95 in 2^nd trimester, difference is 6.97 with the ‘p’ value of 0.001** & effect size is 0.87(Large). 1^st trimester mean and SD of stress is 22.50±8.64 & 15.37±7.26 in 2^nd trimester, difference is 7.13 with the ‘p’ value of 0.001** & effect size is 0.90(Large).

Conclusion

Pregnancy serves as a unique life experience that poses increased risk for negatively affecting both psychological and physical wellness among women. Psychologically, women may face an amplification of stress and affective disturbance in attempting to emotionally and physiologically adjust to the transition to motherhood. Similarly, women classified as reporting high levels of depressive symptoms at both time points were shown to have significantly higher anxiety & stress. Research has shown, for instance, that depression and anxiety can increase her risk for preterm labor. Untreated, these conditions can hamper her ability to care for herself and her developing baby. The study conducted by Van den Bergh BR, et al ,(2005), in Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms also supports this fact. Karmaliani R, et, al,(2007) while studying Diagnostic validity of two instruments for assessing anxiety and depression among pregnant women in Hyderabad, Pakistan, found out , 71 (36%) of the women were diagnosed with depression or anxiety or both.

O'Brien L, et,al,.( 2007), in the study To determine the effectiveness of maintaining antidepressants during pregnancy, as measured by changes in symptoms of depression, anxiety, irritability, and stress following reassuring evidence-based counseling in a Longitudinal study of depression, anxiety, irritability, and stress in pregnancy following evidence-based counseling on the use of antidepressants, shows Depression scores were highest at enrollment in the first trimester and decreased as pregnancy progressed. This review supports present study .Which came out with the result that indicated significant decrease in depression in 2^nd trimester compared to 1^st trimester, where as highly significant decrease in anxiety & stress in 2^nd trimester compared to 1^st trimester.

Limitations of the study

The sample was not representative of the urban population. The sample size was very small. The effect of demographic variables was not studied.

Suggestion for the further study

The effect of demographic variables can be studied to know the reasons for depression, anxiety & stress. The study highlights the need to allocate resources and develop strategies of individual & family counseling, dietician guidance, yoga, meditation to make the woman journey during pregnancy without depression, anxiety & stress.

Acknowledgment

We convey our sincere thanks to the Medical officer & staff Primary health center Bageshpur for giving us permission to collect the data and for their cooperation for our research work. We are thankful to all our respondents for their co-operation. We are thankful to Mr. Suresh Department of Statistics, Animal and Research Center, Bangalore for all the help rendered to us in the data analysis. We are thankful to our family and friends.

References:

1. Van den Bergh BR, Mulder EJ, Mennes M, Glover V,(2005), in Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review, Neuroscience Biobehaviour Rev,2005,29(2),237.
2. O'Brien L, Schachtschneider AM, Koren G, Walker JH, Einarson A.(2007), Longitudinal study of depression, anxiety, irritability, and stress in pregnancy following evidence-based counseling on the use of antidepressants. J Psychiatry Practice,2007,jan:13(1):33-39
3. Rozina Karmaliani, Nargis Asad , Carla M. Bann , Nancy Moss , Elizabeth M. Mcclure, Omrana Pasha , Linda L. Wright, Robert L. Goldenberg ,(2009), Prevalence of Anxiety, Depression and Associated Factors Among Pregnant Women of Hyderabad, Pakistan, International Journal of Social Psychology, sept 2009:55(5):414-424: E pub 2009 Jul 10.
4. Parcells, D.A.(2010), Women's mental health nursing: depression, anxiety and stress during pregnancy, Journal of Psychiatric & Mental Health Nursing:Nov 2010:17(9):813-820.
5. Karmaliani R, Bann CM, Pirani F, Akhtar S, Bender RH, Goldenberg RL, Moss N.(2007),Diagnostic validity of two instruments for assessing anxiety and depression among pregnant women in Hyderabad, Pakistan,Health Care Women Int,(2007),Jul:28(6):556-572.
6. Kaniz Gausia, Colleen Fisher, Mohammed Ali and Jacques Oosthuizen (2009), Antenatal depression and suicidal ideation among rural Bangladeshi women: a community-based study, Archives of women’s mental health,2009:12(5):351-358.
7. Bernard Rosner (2000), Fundamentals of Biostatistics, 5^th Edition, Duxbury, page 80-240
8. Robert H Riffenburg (2005) , Statistics in Medicine , second edition, Academic press. 85-125.
9. Sunder Rao P S S , Richard J : An Introduction to Biostatistics, A manual for students in health sciences , New Delhi: Prentice hall of India. 86-160

Table 1: Age distribution of pregnant women studied

Age in years	Number of women	%
20-25	21	70.0
26-30	9	30.0
Total	30	100.0

Graph.1

Table 2: Pearson correlation

Pair of variables	1st trimester		2nd trimester
	r value	p value	r value	p value
Depression vs. Anxiety	0.782	<0.001**	0.819	<0.001**
Depression vs. Stress	0.821	<0.001**	0.689	<0.001**
Anxiety vs. Stress	0.870	<0.001**	0.764	<0.001**

Graph 2

Table 3: Levels of depression, Anxiety & stress levels at 1^st trimester and 2^nd trimester

Variables	1st trimester	2nd trimester	Difference	P value	Effect size
Depression	18.67±8.59	13.37±9.10	5.30	0.023*	0.60(moderate)
Anxiety	20.87±9.07	13.90±6.95	6.97	0.001**	0.87(Large)
Stress	22.50±8.64	15.37±7.26	7.13	0.001**	0.90(Large)

Graph 3

Chandrakant Jamadar

Asst.Professor

P