Abstract
Background:
Pregnancy is considered prone to encountering frequent mood changes and emotional disturbances such as stress and mixed anxiety-depressive symptoms. Compromised maternal mental health in the pre-natal period may result in physical complications in newborns like low birth weight, preeclampsia and preterm births with the increased neonatal morbidity.
Aim:
To estimate the prevalence of the depression, anxiety, stress, and the factors associated with it, among pregnant women attending antenatal clinics.
Material and Methods:
A cross-sectional study among pregnant women of all trimesters, who attended the antenatal clinic were included. Pregnant women with pre-existing mental health conditions (such as depression, anxiety, or stress) were excluded. Sample size was taken as 314. A semi-structured questionnaire derived from the DASS-21 (Depression, Anxiety and Stress Scale-21 questions) tool was used to assess depression, anxiety, and stress. The responses were classified into different severity levels: normal, mild, moderate, severe, and extremely severe.
Results:
92.9% of the mothers were aged above 20 years and among them 52.5% were uneducated. Majority of the participants were suffering from symptoms of anxiety (27.8%), followed by stress (22.92%) and depression (19.1%), most of them being mild and moderate. Factors significantly affecting depression, anxiety and stress were their occupation, co-morbidity, partner support and history of anxiety and depression. In most cases, emotional support from the participant’s mother was sufficient (87.26%) and partner support was also satisfactory. (95.22%).
Conclusion:
This study revealed the high prevalence of anxiety, depression and stress symptoms in antenatal mothers attending antenatal care services.
Keywords: Antenatal care, anxiety, mental health, prenatal depression, stress
The prevalence of antenatal depression varies widely across studies, with estimates ranging from 4% to 81%, influenced by socio-demographic factors, geographical location, and cultural context. In developed countries, studies show that the prevalence of depression during pregnancy is approximately 10%–20%, whereas, in low- and middle-income countries, the prevalence can be considerably higher due to the various factors like poor access to healthcare, financial instability, and limited social support systems. For example, a study conducted in Sweden reported that nearly 14% of expectant mothers experienced some form of psychiatric illness, including depression and anxiety.[1] Furthermore, research indicates that factors like young maternal age, lower educational levels, poor socio-economic status, and stressful life events contribute significantly to the risk of antenatal depression.[2,3]
Anxiety and stress during pregnancy are also major concerns, with studies revealing that the conditions are often under recognized and undertreated. The risk factors for antenatal anxiety and stress overlap with those for depression and include low income, relationship problems, substance abuse, and history of mental illness.[4] Women who experience significant emotional distress during pregnancy are more likely to have poor pregnancy outcomes, such as gestational hypertension, preeclampsia, and complications during delivery.[5] Despite the growing awareness of the maternal mental health, mental health screening and treatment remain limited in many parts of the world. In many developing countries, maternal health programs primarily focus on the physical health, such as nutrition and prenatal care, while mental health issues often go unaddressed.[6] This gap in care calls for a more integrated approach that includes mental health screening, diagnosis, and management as part of routine antenatal care. Given the widespread impact of antenatal mental health issues on maternal and child health, it is crucial to identify the prevalence and associated risk factors for depression, anxiety, and stress symptoms in pregnant women. This study aims to examine the prevalence of symptoms of these conditions among antenatal women and explore the factors that contribute to their occurrence in a facility-based setting.
MATERIALS AND METHODS
A cross-sectional study was conducted in a tertiary care hospital in Hyderabad, which has a 700-bed capacity and primarily serves insured individuals. All the antenatal mothers coming to antenatal clinic satisfying inclusion and exclusion criteria were included in the study.
Inclusion and exclusion criteria
Pregnant women from all trimesters, who attended the antenatal clinic between August and September 2022 were included in the study. Pregnant women with pre-existing mental health conditions (such as depression, anxiety, or stress) were excluded to focus on pregnancy-related emotional distress.
Sample size calculation
The sample size was calculated considering the prevalence of depression in antenatal women of 35.7%,[6] with a 95% confidence level and 5% precision, resulting in a total of 314 participants.
Tools
The Depression, Anxiety, and Stress Scale-21 Items (DASS-21)[7] was used to assess the emotional health of participants. The scale is divided into three subscales. Each subscale consists of seven items, and participants rated their symptoms based on a 4-point severity scale (0 = does not apply to me, 1 = applies to me to some degree, 2 = applies to me to a considerable degree, 3 = applies to me most of the time). Recommended cut-off scores for conventional severity labels (normal, mild, moderate, severe and extremely severe) are available.[7]
Data collection
A semi-structured questionnaire derived from the DASS-21 tool was used to assess depression, anxiety, and stress. The Semi-structured questionnaire consisted of Demographic characteristics, Pregnancy related characteristics of antenatal mothers and DASS-21 scale. After getting informed oral consent from the antenatal mothers, the data was collected through face-to-face interviews in local languages with the scores rated by the principal investigator. Participants identified with depression, anxiety, or stress symptoms were referred to a psychiatrist for further evaluation and treatment.
Statistical analysis
The collected data was entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) version 22. Descriptive statistics were used to express the prevalence of depression, anxiety, and stress. Chi-square tests were used to explore associations between mental health conditions and demographic factors, with a P value of < 0.05 considered statistically significant.
RESULTS
A total of 314 women who were eligible for the study were included. The demographic characteristics of the participants were as follows: Most of the participants (92.9%) were aged above 20 years. Most of the participants were Hindus (84.4%), followed by Muslims (8.6%), Christians (5.7%), and others (1.3%). More than half of the participants (52.54%) were not highly educated. A significant proportion of the participants were unemployed (64.9%). Most participants had a family monthly income above 10,000 INR (89.5%). Most participants belonged to a nuclear family (56.68%), while a small percentage came from a three-generation family (2.2%). Most participants (98.7%) lived with their husbands [Table 1].
Table 1.
Socio-demographic profile of the ANC mothers
| Variable | n (%) | |
|---|---|---|
| Age | ≤20 years >20 years |
22 (7.1) 292 (92.9) |
| Religion | Hindu Muslim Christian Others |
265 (84.4) 27 (8.6) 18 (5.7) 4 (1.3) |
| Education | Below graduate Graduate Postgraduate |
165 (52.54) 124 (39.5) 25 (7.96) |
| Occupation | Government Private Self-employed Business Homemaker |
11 (3.5) 76 (24.2) 21 (6.6) 2 (0.63) 204 (64.9) |
| Family Income | <10,000 >10,000 |
33 (10.5) 281 (89.5) |
| Type of family | Nuclear Joint 3-generation |
178 (56.68) 129 (41) 7 (2.2) |
| Marital status | Staying with husband Away from husband |
310 (98.7) 4 (1.3) |
Among the 314 pregnant women, the highest number of responses came from those experiencing their second pregnancy (47.77%). Most women were in their third trimester (49.68%). Most women (68.15%) reported never having a miscarriage or abortion. Physical violence from the spouse was absent in the most cases (97.14%). Emotional support from the mother was sufficient for most participants (87.26%), and partner support was satisfactory for most (95.22%) [Table 2]. None of the women had any history of psychiatric treatment during a previous pregnancy or in the past.
Table 2.
Pregnancy-related characteristics of ANC mothers
| Variable | n (%) | |
|---|---|---|
| Parity | Nulliparous Primiparous Multiparous (≥2) |
86 (27.38) 150 (47.77) 77 (24.52) |
| Current Pregnancy months | 1st trimester 2nd trimester 3rd trimester |
37 (11.7) 120 (38.21) 156 (49.68) |
| Spouse physical violence | Present Absent |
9 (2.86) 305 (97.14) |
| Emotional support from the mother | Sufficient Insufficient |
274 (87.26) 30 (9.55) |
| Catastrophic event (within last 3 months) | Yes No |
19 (6.05) 294 (93.63) |
| H/o anxiety and/or depression | Yes No |
4 (1.27) 310 (98.7) |
| Previous or past abortion | Yes No |
100 (31.8) 214 (68.15) |
| Previous preterm delivery | Yes No Not applicable |
22 (7) 253 (80.57) 39 (12.42) |
| Comorbidity in current pregnancy (hypertension, diabetes, hypothyroid, any other) | Yes No |
94 (29.93) 220 (70.06) |
| Partner support | Satisfactory Non-satisfactory |
299 (95.22) 15 (4.78) |
Among the antenatal women, 27.8% reported suffering from anxiety, 22.92% were affected by stress and 19.1% reported symptoms of depression [Figure 1]. Several factors were found to significantly affect the mental health outcomes of the participants: Factors significantly associated with the depression, included occupation, catastrophic events, co-morbidity, partner support, and a history of anxiety and depression. Significant factors influencing anxiety were occupation, spouse physical violence, catastrophic events, co-morbidity, partner support, a history of anxiety and depression, and a history of psychiatric treatment. Factors significantly affecting stress, included occupation, spouse physical violence, emotional support from the mother, catastrophic events, past abortions, previous preterm delivery, co-morbidity, partner support, and a history of anxiety and depression [Table 3].
Figure 1.
Distribution of study participants according to depression, anxiety and stress
Table 3.
Association of depression, anxiety and stress with socio-demographic and other characteristics
| Variable | Depression Symptoms |
P | Anxiety Symptoms |
P | Stress Symptoms |
P | |||
|---|---|---|---|---|---|---|---|---|---|
| No (%) | Yes (%) | No (%) | Yes (%) | No (%) | Yes (%) | ||||
| Age | 0.293 | ||||||||
| • 1 (18–20) | 19 (86.4) | 3 (136) | 0.66 | 15 (68.2) | 7 (31.8) | 0.67 | 16 (72.7) | 6 (27.3) | |
| • 2 (21–50) | 229 (80.1) | 57 (199) | 207 (72.4) | 79 (276) | 234 (81.8) | 52 (18.2) | |||
| Family monthly income | 0.66 | 0.48 | 0.336 | ||||||
| • <20000 | 160 (81.6) | 36 (18.4) | 145 (74.0) | 51 (26.0) | 163 (83.2) | 33 (16.8) | |||
| • >20000 | 94 (79.7) | 24 (20.3) | 83 (70.3) | 35 (29.7) | 93 (78.8) | 25 (21.2) | |||
| Occupation | |||||||||
| • Employed | 82 (745) | 28 (25.5) | 0.03* | 71 (64.5) | 39 (355) | 0.01* | 90 (81.8) | 20 (18.2) | 0.92 |
| • Un-employed | 172 (84.3) | 32 (15.7) | 157 (77.0) | 47 (230) | 166 (81.4) | 38 (18.6) | |||
| Religion | 0.52 | 0.45 | 0.45 | ||||||
| • Hindus | 213(80.4) | 52 (19.6) | 192 (72.5) | 73 (275) | 192 (72.5) | 73 (27.5) | |||
| • Non-Hindus | 38 (84.4) | 7 (156) | 35 (77.8) | 10 (22.2) | 35 (77.8) | 10 (22.2) | |||
| Education | 0.29 | 0.42 | 0.13 | ||||||
| • Below graduate | 138 (83.6) | 27(16.4) | 124 (75.2) | 41 (248) | 130 (730) | 48 (27.0) | |||
| • Graduate | 95 (76.6) | 29 (23.4) | 85 (68.5) | 39 (315) | 102 (82.3) | 22 (17.7) | |||
| • Postgraduate | 21 (84.0) | 4(16.0) | 19 (76.0) | 6 (24.0) | 24 (96.0) | 1 (4.0) | |||
| Type of family | 0.24 | 0.84 | 0.84 | ||||||
| • Nuclear | 148 (83.1) | 30 (16.9) | 130 (73.0) | 48 (27.0) | 130 (73.0) | 48 (27.0) | |||
| • joint and 3 generation | 106 (77.9) | 30 (22.1) | 98 (72.1) | 38 (27.9) | 98 (72.1) | 38 (27.9) | |||
| Spouse physical violence | 0.12 | 0.02** | 0.01** | ||||||
| • Absent | 249 (81.6) | 56 (18.4) | 225 (73.8) | 80 (26.2) | 253 (83.0) | 52 (17.0) | |||
| • Present | 5 (556) | 4 (444) | 3 (33.3) | 6 (66.7) | 3 (33.3) | 6 (66.7) | |||
| Experience of emotional support from the mother | 31 (775) | 9(22.5) | 0.55 | 28 (70.0) | 12 (30.0) | 0.83 | 27 (67.5) | 13 (32.5) | 0.01* |
| • Insufficient | 223 (81.4) | 51(18.6) | 200 (73.0) | 74 (27.0) | 229 (83.6) | 45 (16.4) | |||
| • Sufficient | |||||||||
| Catastrophic event (within last 3 months) | 0.01* | 0.00* | 0.00* | ||||||
| • No | 244 (83.0) | 50 (170) | 220 (74.8) | 74 (25.2) | 248 (84.4) | 46 (15.6) | |||
| • Yes | 9 (474) | 10 (52.6) | 7 (36.8) | 12 (63.2) | 7 (36.8) | 12 (63.2) | |||
| Parity | 0.70 | 0.60 | 0.09 | ||||||
| • Nulliparous | 71 (82.6) | 15 (17.4) | 66 (76.7) | 20 (23.3) | 75 (87.2) | 11 (12.8) | |||
| • Primiparous | 123 (82.0) | 27(18.0) | 106 (70.7) | 44 (29.3) | 123 (82.0) | 27 (18.0) | |||
| • Multiparous | 60 (77.9) | 17 (22.1) | 56 (72.7) | 21 (27.3) | 57 (740) | 20 (26.0) | |||
| Previous/past abortions | 0.92 | 0.57 | 0.02* | ||||||
| • Abortion | 62 (80.5) | 15 (195) | 54 (70.1) | 23 (29.9) | 56 (72.7) | 21 (27.3) | |||
| • No abortion includes not applicable | 192 (81.0) | 45 (190) | 174 (73.4) | 63 (26.6) | 200 (84.4) | 37 (15.6) | |||
| Previous preterm delivery | 0.31 | 0.32 | 0.00* | ||||||
| • No | 238 (81.5) | 54 (18.5) | 214 (733) | 78 (26.7) | 243 (83.2) | 49 (16.8) | |||
| • Yes | 16 (72.7) | 6(27.3) | 14 (636) | 8 (36.4) | 13 (59.1) | 9 (40.9) | |||
| H/o Co-morbidity (hypertension/diabetes/ hypothyroid/any other) in current pregnancy | 0.00* | 0.00* | 0.00* | ||||||
| • No | 60 (63.8) | 34 (36.2) | 50 (532) | 44 (46.8) | 68 (72.3) | 26 (27.7) | |||
| • Yes | 194 (88.2) | 26 (11.8) | 178 (80.9) | 42 (19.1) | 188 (85.5) | 32 (14.5) | |||
| Partner Support | 0.00* | 0.00** | 0.00* | ||||||
| • Non-satisfactory | 6 (40.0) | 9 (60.0) | 3 (20.0) | 12 (80.0) | 8 (53.3) | 7 (46.7) | |||
| • Satisfactory | 248 (82.9) | 51 (171) | 225 (753) | 74 (24.7) | 248 (82.9) | 51 (17.1) | |||
| H/o anxiety and/or depression | 0.00* | 0.00* | 0.00* | ||||||
| • No | 216 (85.0) | 38 (15.0) | 199 (78.3) | 55 (21.7) | 221 (87.0) | 33 (13.0) | |||
| • Yes | 38 (63.3) | 22 (36.7) | 29 (48.3) | 31 (51.7) | 35 (58.3) | 25 (41.7) | |||
| H/o psychiatric treatment during a previous pregnancy or at any time during the lifetime | 0.00** | 0.02* | 0.42 | ||||||
| • No | 246 (81.7) | 55 (18.3) | 222 (73.8) | 79 (26.2) | 247 (82.1) | 54 (179) | |||
| • Yes | 80 (94.1) | 5 (59) | 6 (46.2) | 7 (53.8) | 9 (69.2) | 4(30.8) | |||
*Chi-square tests. **Chi-square tests with Yates correction
DISCUSSION
This study aimed to investigate the prevalence of depression, anxiety, and stress symptoms among antenatal women and the factors associated with these mental health conditions. The findings reveal that mental health concerns are common, among the pregnant women in this sample, with anxiety being the most prevalent condition (27.8%), followed by stress (22.92%) and depression (19.1%). This is consistent with existing literature, where mental health issues during pregnancy, particularly anxiety and depression, are reported to be significant challenges for antenatal women globally.[8,9] These findings underscore the urgent need for early screening and interventions aimed at improving the mental health of pregnant women.
Several socio-demographic factors were found to be significantly associated with mental health outcomes in this study. Most participants were over the 20 years (92.9%) and unemployed (64.9%). Unemployment has been identified in various studies as a significant risk factor for the maternal mental health issues. The absence of financial stability may contribute to feelings of helplessness, anxiety, and stress during pregnancy.[10] Moreover, most women in this study had a family monthly income above 10,000 INR (89.5%), which suggests a relatively stable economic status. However, even women with adequate income may experience mental health challenges due to the psychological and emotional stress of pregnancy.[11]
The study found that social support, both from partners and mothers, played a crucial role in protecting against mental health issues. A significant number of women reported satisfactory partner support (95.22%) and emotional support from their mothers (87.26%). Research has consistently demonstrated the positive impact of social support on maternal mental health, with partner support being a key protective factor against depression and anxiety.[12,13] The presence of supportive relationships appears to mitigate some of the emotional and psychological challenges faced by pregnant women, reducing the risk of developing mental health conditions.
Reproductive history, including previous abortions, preterm deliveries, and miscarriages, was another factor influencing mental health outcomes. The study found that the most women had no history of miscarriage (68.15%) or preterm delivery (80.57%) and reported that spouse physical violence was rare (97.14%). However, the occurrence of catastrophic life events, such as loss or serious illness, was a significant risk factor for anxiety and stress. Life stressors and traumatic events are known to trigger mental health issues, particularly during pregnancy, a time that may already be emotionally and physically taxing.[14]
The prevalence rates of anxiety, stress, and depression observed in this study are concerning. Anxiety was the most common condition (27.8%), followed by stress (22.92%) and depression (19.1%). These rates are higher than the global estimates of antenatal depression, which range from 10%–20% in developed countries.[15] However, in developing countries like India, the rates of antenatal mental health disorders may be higher due to the socio-economic stressors, the lack of access to mental health services, and cultural factors surrounding mental health.[16]
Several factors were found to be significantly associated with mental health outcomes, such as occupation, catastrophic events, co-morbidities, partner support, and a history of mental health conditions. Women with a history of anxiety or depression were at a significantly higher risk of experiencing these conditions during pregnancy, which aligns with the findings of other studies that emphasize the continuity of mental health issues from pre-pregnancy to pregnancy.[4,17] Additionally, women experiencing catastrophic life events were more likely to report higher levels of anxiety and stress, further confirming the negative impact of life stressors on maternal mental health.[18]
The findings from this study highlight the prevalence of anxiety, stress, and depression among antenatal women and emphasize the role of various psychosocial and health-related factors in influencing these the mental health conditions. The high rates of anxiety and stress underscore the need for early screening and mental health support for pregnant women, especially those who are unemployed, have a history of psychiatric disorders, or face challenging life events. Additionally, partner support, emotional support from the mother, and a history of mental health conditions emerged as key factors associated with the mental health status of the participants, suggesting that social support plays a critical role in mitigating mental health issues during pregnancy. This study contributes valuable insights that could inform interventions aimed at improving the mental health and well-being of pregnant women, particularly in settings like the one examined in this study. Further research with larger sample sizes and diverse populations is needed to strengthen the understanding of these associations and improve maternal mental health care programs.
Implications for practice
This study highlights the high prevalence of anxiety, stress, and depression among pregnant women, stressing the need for integrated mental health care. Healthcare providers should screen for mental health issues during antenatal visits and offer referrals for counselling or psychiatric care. Policies should improve access to mental health services, especially in low-resource settings. Social support interventions, such as couples counselling and peer support groups, are crucial for reducing mental health risks. The study also calls for further research to guide maternal mental health care programs.
Limitation
DASS-21 is a screening tool to rule out symptoms of depression, anxiety and stress. Using a screening tool and not confirming positive cases with a diagnostic instrument or psychiatrist interview might lead to an overestimation of depression, anxiety and stress rates. Also, the study’s findings have limited generalizability due to its focus on the pregnant women from lower- and middle-income groups, primarily insured individuals at a tertiary care hospital. This may not reflect the experiences of higher-income women with different psychosocial factors and living conditions. It also did not consider adverse obstetric complications or in-law conflicts, which are significant risk factors for antenatal mental health, especially in Southeast Asia.
CONCLUSION
This study found a relatively high prevalence of anxiety, depression, and stress symptoms among antenatal mothers attending a tertiary care hospital. Key factors associated with these symptoms included occupation, spouse physical violence, history of catastrophic events, co-morbidities, history of anxiety and depression, and partner support. Additionally, factors such as history of psychiatric treatment, previous preterm delivery, past abortions, and emotional support from the mother were linked to anxiety and stress. The study highlights the importance of including screening for these mental health conditions in antenatal care to prevent potential adverse effects on both the mother and fetus.
Authors’ contributions
First three authors conceived of the presented idea, developed the theory, and performed the computations. All the authors verified the analytical methods. supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.
Data availability statement
Data can be made available on reasonable request.
Ethical statement
Ethical clearance was obtained from the Institutional Ethics Committee (Ref No: ESICMC/SNR/IEC-F625/09-2024). All participants were provided with a participant information sheet and gave informed consent before participating in the study. Confidentiality was maintained throughout the data collection process.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data can be made available on reasonable request.
