Anxiety, stress, and psychological capital among multiparous women: a cross-sectional study of second pregnancies

Abstract

Background

The transition to motherhood during a second pregnancy can present distinct psychological challenges, particularly anxiety and stress, despite prior maternal experience. Psychological capital (PsyCap), comprising hope, optimism, self-efficacy, and resilience, may buffer these adverse effects. This study explores the interrelationships between anxiety, perceived stress, and psychological capital among women pregnant with their second child.

Methods

A descriptive correlational study was conducted on 400 women attending antenatal clinics in Port Said, Egypt. Participants completed structured interviews using validated tools: the Self-Rating Anxiety Scale (SAS), the Perceived Stress Scale (PSS), and the Psychological Capital Questionnaire (PCQ-24). Sociodemographic and obstetric data were also collected.

Results

Moderate anxiety (84.8%) and moderate-to-high perceived stress (90.8%) were prevalent, while 71.0% of women demonstrated low psychological capital. Anxiety and stress were significantly correlated (p < 0.01), and both were negatively correlated with psychological capital (p < 0.01). Multivariate regression identified working status, income, healthcare quality, pregnancy planning, and fetal gender preference as significant predictors of psychological outcomes.

Conclusions

Women experiencing their second pregnancy are at high risk of moderate psychological distress. Low psychological capital intensifies vulnerability to anxiety and stress. Antenatal interventions that assess and strengthen psychological capital could be key to improving maternal mental health outcomes in subsequent pregnancies.

Introduction

Pregnancy is a unique time in every woman’s life, marked by feelings of happiness and dramatic events, as it involves significant physiological and psychological changes [1]. Pregnant women may experience the discomforts of pregnancy and overwhelming pressures due to changes in their family and social life [2]. In turn, this results in low confidence and feelings of weakness that cause prenatal anxiety and stress, which are widely recognized psychological wellbeing issues during pregnancy, with the prevalence varying from 6.0% to 57.0% and 25% to 75%, respectively [3–5].

Commonly, women in their second pregnancy are predicted to have better psychological adaptations as they have more pregnancy-related knowledge and self-care abilities based on their experience [6]. However, they are generally older and face pressure from family life, career, and even social life. Therefore, they may experience undesirable emotions, such as negativity, anxiety, and stress, which can impact their psychological wellbeing [7]. A study by Liang & Xie, reported that more psychological problems among women in China during their second pregnancy than those in their first pregnancy [8].

Antenatal anxiety is related to the pregnancy, labor, delivery, the wellbeing of the fetus, the wellbeing of the mother, the availability and quality of healthcare resources, and the capacity to parent [9]. Stress is considered a reaction to anything that disturbs a person’s mental or physical equilibrium and interrupts normal functioning. When we perceive the situation as threatening and cope with thinking, it becomes perceived stress. That, strongly correlates with anxiety [10, 11]. These psychological wellbeing issues adversely affect the health of both the fetus and the mother [12].

Consequently, light is sheds on the importance of psychological capital (PsyCap). It is considered an individual positive psychological resource that can be developed and sustained to boost wellbeing and performance, including: (1) having confidence (efficacy), (2) making a positive attribution (optimism), (3) persevering toward goals (hope), and (4) when beset by problems, sustaining and even exceeding (resilience) [13]. A previous study reported that positive psychological capital plays a crucial role in alleviating the psychological stress associated with coping with pregnancy [14].

In the past few years, mental health has received due attention from conception to antenatal care, to labor, to the postpartum period [15]. As a part of the healthcare team, maternity nurses are in the best position to help mothers cope with pregnancy and motherhood while avoiding common health problems associated with pregnancy. Recognizing maternal mental health in prenatal care can yield several benefits: timely identification of psychological vulnerability, affective deficiencies, communication and interaction deficits, low self-esteem and low capacity for resilience. These above considerations are related to poorer obstetric and perinatal outcomes [16].

Thus, it is a great opportunity to strengthen maternal mental health through an intervention that increases mental health literacy, which subsequently affects their educational willingness regarding their own and their babies’ health including education in breastfeeding and infant development [17]. Nurses should be aware of pregnant women’s needs and the importance of mental health, along with its short-term and long-term effects on the mother and the baby. However, awareness is not enough nurses also need resources to meet support needs when they are identified, as well as referral options to psychologists or psychiatrists if necessary [18].

Significance of the study

Anxiety and stress among women during their second pregnancy are observed worldwide, which could reduce their satisfaction with life and increase the incidence of miscarriage and premature delivery, raising the risk of stillbirth by 80% [19, 20].

Unfortunately, there are no studies on this topic in Egypt, particularly in the city of Port Said; even though Egypt’s sociocultural context (high cesarean rates nearly 72% [21], traditional preferences for male offspring especially when the first child is a female and gendered familial roles) may heighten psychological risks in the population. Thus, exploring the relationship between anxiety, psychological stress, and psychological capital among pregnant women expecting their second child can deepen the understanding of maternal mental health during the unique experience of expecting a subsequent child.

Aims of study

The aim of this study is to:

Explore the relationship between anxiety, stress, and psychological capital among pregnant women with a second child.

Specific objectives

1. Assess anxiety among pregnant women with a second child.

2. Assess psychological stress among pregnant women with a second child.

3. Evaluate psychological capital among pregnant women with a second child.

4. Identify the correlations between anxiety, psychological stress, and psychological capital among pregnant women expecting their second child.

5. Explore potential factors influencing the relationship between anxiety, psychological stress, and psychological capital among pregnant women expecting their second child.

Materials and methods

A descriptive correlational research design was utilized in this study.

Setting

The present study was conducted in Port Said City, Egypt; it is one of coastal governorates which is known for its cultural and social diversity. It comprises seven districts, each contributing to the unique fabric of the community.

Sampling

The study employed two types of sampling. First, the study settings were selected using a stratified random sampling technique, emphasizing both randomness and representativeness. The first step in the sampling process involved the random selection of two districts from the seven available in Port Said City. This randomization aimed to preclude bias and provide an equal chance for any district to be included in the study. Random sampling enhances the study’s external validity, allowing findings to be more broadly applicable to the entire city’s population. Within the chosen districts, a random sampling technique was further applied to select two specific healthcare units for the study.

El-Kwait and Othman Ibn Affan units appeared as the randomly chosen healthcare units, adding an additional layer of unbiased representation. Randomly selecting a healthcare units helps prevent potential selection bias, ensuring that the study’s outcomes are not skewed by favoring a particular setting. The sampling strategy was critical for acquiring a diverse and representative sample of pregnant women accessing healthcare services in Port Said. By incorporating randomness at both the district and healthcare unit levels, the study aimed to capture the heterogeneity of the population. This comprehensive approach ensures that the findings are not confined to a specific subset of the community, promoting the generalizability of the study’s outcomes.

Second, the participants (pregnant women) were chosen using a purposive sampling technique, as they met the specific inclusion criteria relevant to the research objectives.

Sample size

The sample size was determined by the Epi-info 7 program using the following parameters:

1. Population size = 36,500 (the number of births in Port Said City). (Data about total number of births obtained from patients’ affairs, 2023).

2. Expected frequency = 25.8%.

3. Acceptable error = 10%

4. Confidence coefficient = 95%.

The program revealed that the sample size = 360 pregnant women. Due to the expected non-participation rate of 10%, the final sample size will be 400 pregnant women who received routine care.

• Inclusion criteria: Adult women aged between 18 and 40 years, who are available at the time of data collection, free from chronic medical conditions, within 12 to 38 weeks of gestation, carrying a singleton pregnancy, and literate.

• Exclusion criteria (meeting any of the following): In active labor, had personal history and family history of diagnosed mental disorders, were carrying fetuses with known fetal abnormalities or stillbirths.

Tools of data collection

Data were collected by using the following tools

A structured interviewing sheet was meticulously crafted by the researchers, based on a thorough review of relevant literature [22, 23]. It included two parts:

• Part 1: Personal characteristics: includes maternal age, educational level, working status, educational level of husband, and whether satisfied with residence and health service of hospitals.

• Part 2: Gestational status data: includes gender expectation for offspring, whether they have a fear of childbirth, gestational complications, whether this pregnancy is planned, whether they have learned antenatal care knowledge and whether they take the prenatal examination on schedule, week of gestation, number of abortions, postpartum complications of previous pregnancies and time of last delivery.

Self-rating anxiety scale (SAS)

To assess the level of anxiety developed in an English language by Zung [24]. It was translated into Arabic Language using the translation-back-translation technique as recommended by Behling & Law [25].This includes 20 items to assess the participants’ anxiety on a 4-point Likert scale (1 = none or little of the time to 4 = most or all of the time).

Scoring: Higher scores indicated a higher degree of anxiety. The SAS scores were classified as follows: mild anxiety (50–59), moderate anxiety (60–69), and severe anxiety (≥ 70). The SAS showed internal consistency reliability of 0.66–0.80.

Perceived Stress Scale (PSS)

The scale consisted of 10 items used to assess how different situations affect feelings and perceived stress, developed by Cohen et al. [26].The Arabic version was obtained from the official website of the PSS (https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/index.html, accessed on 5 March 2024).

Scoring: The response to each scale item was on a 5-point Likert scale ranging from “Never” (0) to “Very often (4).” These were scored from 0 to 4, with reverse scoring for the positive items (4, 5, 7, and 8); the total score of the ten items (range 0–40) was dichotomized into low perceived stress (score 0–27) and high perceived stress (28+) according to tool instructions. The PSS showed internal consistency reliability of 0.58–0.80.

Psychological Capital Questionnaire (PCQ-24)

Developed in the English language by Luthans [27], these 24 items measure four components of psychological capital: self-efficacy, hope, optimism, and resilience. It was translated into Arabic Language using the translation-back-translation technique as recommended [25].

Scoring: Each item is rated on a 6-point Likert scale (1 = strongly disagree to 6 = strongly agree), high psychological capital (> 60%), and low psychological capital (< 60%). The total scale demonstrated excellent reliability with a Cronbach’s alpha of 0.923.

Ethical Consideration

Ethical approval for conducting the study was obtained from the Research Ethics Committee in the Faculty of Nursing, Port Said University. All ethical principles were strictly adhered to throughout the research process. Oral consent was obtained from each participant after explaining the aim of the study and its procedures. Participants were assured of the confidentiality of all collected data, which would be used solely for research purposes. Privacy and anonymity were maintained at all stages of data handling. Moreover, Participants were informed of their right to voluntarily withdraw from the study at any point before its completion without any negative consequences. The study procedures posed no actual or potential harm to the participants.

Procedure of Work

The fieldwork for the study was conducted over five months, from early May 2024 to late September 2024. A total of 400 pregnant women were recruited from the antenatal clinics of two primary health care units in Port Said City. Eligible participants were identified during their routine prenatal examinations and were thoroughly informed about the study’s purpose and procedures. Oral consent was obtained from all participants before data collection.

Data was collected through face-to-face interviews using a predesigned tool and self-reported questionnaires with unified and standardized instructions. Each participant required approximately 10–15 min to complete the questionnaires.

Tool Validity:

The content validity of data collection instruments was evaluated after the transaltion- back- translation technique by a panel of nine experts specializing in obstetrics, gynecological nursing, and psychiatric nursing. The experts reviewed the tools for clarity, relevance, comprehensiveness, and applicability to the study objectives, ensuring that they accurately captured the intended constructs and met cultural adaptation.

Reliability

Cronbach’s alpha (α) coefficient was calculated to assess the reliability of the developed tool through its internal consistency.

Pilot study

Before actual data collection started, a pilot study was conducted after the tool had been reviewed and approved by experts. The goal of the pilot study was to confirm that the research instrument was clear and applicable and to identify potential data collection barriers and concerns. It also helped in estimating the time required to complete the questionnaire. The test was performed on 10% of the 40 women in the study who were excluded from the final research sample. Internal, external, and inference validity were assessed. Based on the results of the pilot study, some questions were revised, clarified for participants, omitted such detailed data regarding present pregnancy, and rearranged to ensure the stability of the answers, as reliability of collected data was 0.8 for SAS, 0.76 for PSS and 0.9 for PCQ-24.

Statistical design

In this study, statistical analyses were conducted using SPSS 26. We first descriptively analyzed the socio-demographic characteristics and presented the measurement data as mean and standard deviation, and the enumeration data as frequency. Chi-square tests, one-way ANOVA, Student’s t-test, multiple linear regression analyses were conducted using the SPSS Inc. statistical program for windows (Chicago, CA, USA).

Results

Descriptive statistics

Table 1: The results indicate that the majority of participants (more than three-quarters) were aged over 25 years, with a mean age of 27.7 ± 4.1 years. Over two-thirds of the women were housewives, and approximately one-third had attained a university-level education. In contrast, nearly two-fifths of their husbands had completed university education. Additionally, more than three-quarters of the participants reported having a sufficient household income.

Table 1.

Personal characteristics (demographic and obstetric) of participants

Personal Characteristics N=(400)	Frequency	Percent	obstetric characteristics	Frequency	Percent
Age:			Pregnancy time (weeks):
< 25	96	24.0	First/Second trimester	57	14.3
25+	304	76.0	Third trimester	343	85.8
Range	19.0–37.0		Range	10–37
Mean ± SD	27.7 ± 4.1		Mean ± SD	29.6 ± 4.6
Median	28.00		Median	30.0
Job:			Had scheduled investigations done:
Housewife	272	68.0	No	56	14.0
Working	128	32.0	Yes	344	86.0
Education:			Had fears about labor:
Basic	17	4.3	No	119	29.8
Secondary	260	65.0	Yes	281	70.3
University	123	30.8
Husband education:			Got enough antenatal information:
Basic	32	8.0	No	129	32.3
Secondary	213	53.3	Yes	271	67.8
University	155	38.8
obstetric characteristics Family income:			Had abortions:
Insufficient	96	24.0	No	361	90.3
Sufficient	304	76.0	Yes	39	9.8
Local health care quality:			Last labor mode:
Poor	134	33.5	Normal vaginal	25	6.3
Good	266	66.5	Cesarean	375	93.8
Current pregnancy:			Last labor time (years):
Unplanned	73	18.3	< 2	209	52.3
Planned	327	81.8	2+	191	47.8
Fetus gender accepted:			Had labor complications:
No	94	23.5	No	333	83.3
Yes	306	76.5	Yes	67	16.8

Also, approximately one-third of the participants reported dissatisfaction with the quality of local healthcare services (33.5%), inadequate antenatal information (32.3%), and fear of childbirth (70.3%). Less than one-fifth experienced unplanned pregnancies (18.3%) or had complications in previous deliveries (16.8%). Additionally, 23.5% of participants expressed dissatisfaction with the fetus’s gender.

Moreover, more than one-tenth of those who did not undergo scheduled antenatal investigations (14.0%), were in their first or second trimester at the time of data collection (14.3%). The vast majority had no history of abortion (90.3%), and most reported cesarean section as the mode of their last delivery (93.8%). Regarding the time since their last delivery, less than half (47.8%) indicated more than two years.

As illustrated in Table 2, participants experienced anxiety, with a mean score of 44.9 ± 5.5. Similarly, perceived stress was reported, reflected by a mean score of 18.1 ± 3.4. Their total psychological capital had a mean score of 52.4 ± 12.9.

Table 2.

Anxiety, perceived stress, and psychological capital among women in the study sample (n = 400) scores

	Scores
	Min-max	Mean ± SD	Median
Anxiety:	30.0–64.0	44.9 ± 5.5	45.00
Perceived stress:	9.0–29.0	18.1 ± 3.4	18.00
High (60%+) psychological capital:
Self-efficacy	6.7–93.3	47.1 ± 20.5	46.70
Hope	10.0–93.3.0.3	54.4 ± 15.6	53.30
Resilience	4.0–96.0	47.6 ± 17.6	48.00
Optimism	30.0–90.0	63.4 ± 11.4	65.0
Total capital:
Low
High	23.8–86.7	52.4 ± 12.9	50.50

Figure 1 demonstrates that the majority of participants (84.8%) experienced moderate levels of anxiety.

Fig. 1.

Anxiety among women in the study sample (n=400)

Figure 2 displays that most women (90.8%) reported moderate perceived stress.

Fig. 2.

Perceived stress among women in the study sample (n=400)

Figure 3 shows that slightly less than three-quarters (71.0%) exhibited low levels of total psychological capital.

Fig. 3.

Psychological capital among women in the study sample (n = 400)

Relations Analyses

Table 3 demonstrates that women’s anxiety levels showed no statistically significant association with any of the examined demographic characteristics. However, perceived stress levels were found to have a significant positive association with family income (p = 0.04) as financial insufficiency can increase stress levels. Additionally, a statistically significant positive relationship was observed between psychological capital and women’s employment status and family income (p < 0.01) as the employed women had been financially independent and could build friendships outside their families, which empowered them and could increase their psychological capital.

Table 3.

Relations between women’s anxiety, perceived stress, and psychological capital scores and their characteristics

	Anxiety		Perceived stress		Psychological capital
	X2 test	p-value	X2 test	p-value	X2 test	p-value
Job:
Housewife	1.93	0.17	0.03	0.86	20.40	< 0.001*
Working
Family income:
Insufficient	1.70	0.19	4.38	0.04*	25.81	< 0.001*
Sufficient
Local health care quality:
Poor	8.05	0.005*	0.56	0.45	12.05	0.001*
Good
Current pregnancy:
Unplanned	0.34	0.56	0.21	0.65	30.53	< 0.001*
Planned
Fetus gender accepted:
No	6.53	0.01*	0.93	0.34	18.83	< 0.001*
Yes
Got enough antenatal information:
No	10.58	0.001*	0.28	0.60	8.61	0.003*
Yes
Had scheduled investigations done:
No	2.84	0.09	5.26	0.02*	15.84	< 0.001*
Yes
Had fears about labor:
No	2.67	0.10	0.01	0.94	12.05	0.001*
Yes

(**) Statistically significant at p < 0.01

It also indicates that women’s anxiety was significantly associated with several health and obstetric factors, including dissatisfaction with local healthcare quality, fetal gender unpreference, inadequate antenatal information, and an interval of more than two years since the last delivery (p < 0.005). Perceived stress was significantly related to adherence to scheduled investigations (p < 0.005). Furthermore, low psychological capital was significantly associated with poor healthcare quality, unplanned pregnancy, fetal gender unpreference, lack of antenatal education, absence of scheduled investigations, and labor-related fear (p < 0.005).

As shown in Table 4, there is a significant positive correlation between anxiety and perceived stress scores among participants. Conversely, psychological capital scores showed significant negative correlations with both anxiety and perceived stress scores, indicating that higher psychological capital is associated with lower levels of anxiety and perceived stress.

Table 4.

Correlation matrix of anxiety, perceived stress, and psychological capital scores

Scres	Spearman’s rank correlation coefficient
	Anxiety	Perceived stress	Psychological capital
Anxiety	1.000
Perceived stress	0.081	1.000
Psychological capital	− 0.249**	− 0.179**	1.000

(**) Statistically significant at p < 0.01

Multiple Linear Regression statistics

Table 5 illustrates that eight variables maternal age, working status, husband’s university education, monthly income, planned pregnancy, fetal gender preference, receipt of antenatal information, and history of previous cesarean delivery were significant predictors of psychological capital among women during their second pregnancy (p < 0.05).

Table 5.

Best fitting multiple linear regression model for the psychological capital score

	Unstandardized Coefficients		Standardized Coefficients	t-test	p-value	95% Confidence Interval for B
	B	Std. Error				Lower	Upper
Constant	35.22	6.55		5.377	< 0.001	22.34	48.10
Age	−0.28	0.14	−0.09	−1.949	0.052	−0.55	0.00
Working	−5.35	1.27	−0.19	−4.193	< 0.001	−7.85	−2.84
Husband university degree	2.70	1.25	0.10	2.151	0.032	0.23	5.16
Income	4.42	1.35	0.15	3.273	0.001	1.76	7.07
Planned pregnancy	3.43	1.51	0.10	2.267	0.024	0.46	6.41
Fetus sex wanted	7.69	1.38	0.25	5.558	< 0.001	4.97	10.40
Received information	4.82	1.25	0.18	3.861	< 0.001	2.36	7.27
Previous cesarean	5.26	2.36	0.10	2.230	0.026	0.62	9.90

r-square = 0.24

Model ANOVA: F = 15.32, p < 0.001.Variables entered and excluded: education, husband job, crowding index, previous abortions, fetus gender preference, got information

Table 6 shows that five factors perceived quality of health care, planned pregnancy, fear related to childbirth, time since last delivery, and psychological capital were significant predictors of anxiety levels among women during their second pregnancy (p < 0.05).

Table 6.

Best fitting multiple linear regression model for the anxiety score

	Unstandardized Coefficients		Standardized Coefficients	t-test	p-value	95% Confidence Interval for B
	B	Std. Error				Lower	Upper
Constant	50.89	1.26		40.512	< 0.001	48.42	53.36
Good healthcare	−1.58	0.58	−0.14	−2.713	0.007	−2.72	−0.43
Planned pregnancy	−1.23	0.69	−0.09	−1.779	0.076	−2.60	0.13
Pregnancy fears	−1.72	0.60	−0.14	−2.880	0.004	−2.89	−0.55
Last labor years	0.46	0.22	0.10	2.100	0.036	0.03	0.90
Psychological capital	−0.08	0.02	−0.18	−3.553	< 0.001	−0.12	−0.03

r-square = 0.12

Model ANOVA: F = 11.07, p < 0.001

Variables entered and excluded: age, education and job, husband education and job, income, crowding index, previous abortions and labor, gestation weeks, fetus gender preference, got information

Table 7 demonstrates that fetal gender preference, history of previous cesarean delivery, psychological capital, and anxiety scores were the main predictors significantly influencing perceived stress levels among women during their second pregnancy (p < 0.05).

Table 7.

Best fitting multiple linear regression model for the perceived stress score

	Unstandardized Coefficients		Standardized Coefficients	t-test	p-value	95% Confidence Interval for B
	B	Std. Error				Lower	Upper
Constant	7.17	2.05		3.503	0.001	3.15	11.19
Fetus gender preference	1.19	0.40	0.15	2.933	0.004	0.39	1.98
Previous cesarean	1.41	0.68	0.10	2.088	0.037	0.08	2.74
Psychological capital	0.04	0.01	0.14	2.747	0.006	0.01	0.06
Anxiety score	0.12	0.03	0.19	3.873	< 0.001	0.06	0.18

r-square = 0.09

Model ANOVA: F = 9.57, p < 0.001

Variables entered and excluded: age, education and job, husband education and job, income, crowding index, previous abortions, planned pregnancy, gestation weeks, got information, satisfactory care

Discussion

This study evaluated perceived stress, anxiety, and psychological capital among Egyptian women pregnant with their second child. The findings reveal a predominant experience of moderate anxiety and stress, accompanied by generally low levels of psychological capital. These results underscore significant psychological challenges encountered during second pregnancies, particularly within the sociocultural context of Egypt.

The current study shows majority of participants had CS at an alarming rate, despite Egypt being ranked as the third hieghest globally [28], our results higher than the official statistics. This may be related to social myths that suggest CS is more feasible, fear vaginal delivery, lack of knowledge about benefits of vaginal delivery for mothers and newborns, societal trends and financial interests benefiting obstetricians. Therefore, Ministry of Health and Population made great efforts to encourage women for vaginal delivery and to warn them against CS.

The status of anxiety, psychological stress and psychological capital among women pregnant with their second child

The current study indicates that most participants experienced moderate levels of anxiety during their second pregnancy. Although this level of anxiety does not reflect acute psychological distress, it may still interfere with daily functioning and overall wellbeing. These findings align with previous research that has identified similar patterns of anxiety in pregnant populations [29]. However, compared to earlier studies that reported significantly higher anxiety levels, the current findings suggest comparatively lower severity [30]. This could be attributed to differences in parity, as earlier studies often focused on first-time mothers who may be more susceptible to anxiety due to a lack of prior experience with pregnancy and childbirth.

Moreover, the observed prevalence of moderate anxiety in this population appears to exceed global estimates and regional reports from countries such as Sri Lanka and Bangladesh [31, 32]. This may suggest that women pregnant with a second child in Egypt face unique psychological challenges. Potential contributing factors include emotional immaturity for young mothers who lack experience, lack of social support and role models. Additionally, apprehensions about disruptions to occupational roles and lack of shared parental responsibilities with husbands may play a role.

Furthermore, the manifestation of anxiety during pregnancy can be challenging to differentiate from typical somatic symptoms of pregnancy such as fatigue, low energy, and sleep disturbances complicating both diagnosis and management [33]. These findings underscore the importance of early screening and tailored psychological support for multiparous women to mitigate the adverse effects of prenatal anxiety.

Regarding perceived stress, the findings indicated that most participants experienced moderate levels of perceived stress, consistent with prior studies that have observed similar patterns of stress among pregnant women [34]. Compared to research conducted in countries such as Nigeria, Saudi Arabia, and Nepal, the level of stress in the present study appeared to be relatively elevated [35, 36]. This may be attributed to several socio-demographic factors, including limited educational background, homemaker status, and being in the third trimester circumstances previously linked to higher stress levels in late pregnancy [37, 38]. The third trimester is particularly challenging, marked by considerable physiological and emotional changes [39]. Furthermore, cultural and social expectations in Egypt, where women often assume extensive familial roles, may compound stress during a second pregnancy.

Regarding psychological capital, most participants demonstrated low levels across dimensions, including self-efficacy, hope, resilience, and optimism. These levels were lower than those reported in other studies conducted in different contexts [40, 41]. This could be tied to several contextual and personal factors: low education levels, the stress of managing existing childcare responsibilities, concerns about the current pregnancy, fear of childbirth, and the societal shift towards nuclear family structures (in the past, patriarchal structure of Egyptian families consisted of extended families, meaning that newlywed couples would co-reside with the parents of the groom, who shared responsibilities with each other in times of happiness and sadness; then nuclear families began to spread - a study revealed that nearly three quarters of participants formed nuclear families when they first wed in 2006 and 2012 respectively [42]), which may reduce perceived social support and increase feelings of isolation and helplessness.

Factors influencing anxiety, psychological stress and psychological capital

Contrary to expectations, most participants’ characteristics, such as age, education, employment status, and planning for current pregnancy were not significantly associated with anxiety or perceived stress levels. These findings are consistent with those from similar study in China [43].

In concordance with the present study, Minglu et al. [22]reported in their research that anxiety levels were significantly affected by gender expectations. In many developing countries, gender preference particularly for male offspring continues to exert considerable pressure on women during pregnancy. This sociocultural expectation can contribute to increased levels of antenatal anxiety, as noted by Song et al. [44], who emphasized that gender expectations significantly influence family planning decisions and maternal psychological health.

Additionally, insufficient family income and lack of scheduled medical investigations emerged as significant stressors. These stressors may reflect broader issues of limited support systems and financial insecurity, which are known contributors to prenatal stress [45, 46]. Conversely, a lack of male partner involvement during antenatal visits may exacerbate stress, highlighting the importance of emotional and social support as maternal satisfaction with paternal engagement during prenatal care has been associated with reduced stress [47]. Thus, the literature further supports the value of male partner participation, as it provides emotional, physical, and financial support and fosters a sense of shared responsibility during pregnancy [48].

Moreover, psychological capital was significantly associated with employment status, which may reflect not only economic benefits but also social interaction and personal development opportunities gained through work. In contrast, performing unpaid household tasks may lead to increased social isolation. Supporting this, research has shown a positive correlation between higher education, external employment, and enhanced mental wellbeing [49].

Furthermore, psychological capital was associated with quality of healthcare, planned pregnancy, fetal gender preference, adequate antenatal information, scheduled investigations, and fear about labor; even most participants had no complications after previous delivery, this fear may be related to repeat CS, fear of anesthesia especially spinal, and the inability of the mother to care for her first child during the first week after delivery, especially if she underwent cesarean delivery and may not have familial support, which may increase her anxiety levels. All these conditions can aggravate their fears of birth.

Similarly, prior research has reported that, certain obstetric factors, such as gestational age, pregnancy intention, and history of obstetric complications, were not consistently associated with psychological outcomes [50].

Correlations among anxiety, psychological stress and psychological capital

The relationship between anxiety and perceived stress was positive, a finding echoed in multiple international studies [51, 52]. Conversely, psychological capital demonstrated a negative correlation with both anxiety and perceived stress, indicating that individuals with higher psychological capital tend to approach challenges more optimistically and confidently [53, 54]. Drawing on the literature in positive psychology, it is evident that psychological capital enhances mental health and resilience, equipping individuals to better cope with adversity [55, 56].

Finally, a deficiency in psychosocial resources during pregnancy is associated with disparities in maternal and neonatal outcomes, including higher risks of maternal depression, low birth weight, adverse perinatal outcomes, and challenges in early child development [57–59]. These findings underscore the necessity for comprehensive antenatal care that incorporates psychological assessment and support to safeguard the wellbeing of mothers and their families.

Recommendations

Moreover, these findings have important implications: to avoid adverse consequences of psychological disorders during pregnancy and child outcomes, it is essential to integrate routine psychological assessment into antenatal care (ANC) visits. Healthcare providers should be trained to recognize and address women’s treatment preferences for mental health concerns. Moreover, promoting the active involvement of husbands in ANC and strengthening familial and social support networks can significantly enhance maternal psychological wellbeing.

A policy-level commitment to women’s empowerment, aligned with national directives, is also crucial for promoting psychological resilience among pregnant women. Additionally, further qualitative research using open-ended inquiries is warranted to explore unexamined stressors. Longitudinal and qualitative studies are recommended for better understanding of the related factors.

Strengths and limitations of the study

This study’s strengths include studying large sample size and the usage of validated instruments. Additionally, the research team immediately reviewed all questionnaires to ensure completeness and accuracy. All questionnaire were revised for any missing data; if there was any, it would be completed by the woman who filled it.

This study has some limitations:

1) Cross- sectional design isn’t able to infer causality(e.g., does low psychological capital cause anxiety, or does anxiety deplete psychological capital).

2) There may be social expectation bias or recall bias in self-reported data; thus, the data collection method interviews is highly recommended. 3)Recruitment from only two clinics may limit generalizability, also the study was only conducted in a single governorate, which may have regional constraints. Large-sample multi-governorate studies can be conducted; however, the study was ultimately limited by cultural factors. 4) Internationally validated scales may not fully capture culture- specific concerns (e.g., intense fear of repeat cesarean delivery). Future studies should incorporate qualitative interviews.

Conclusions

The findings of this study indicate that anxiety and perceived stress are prevalent among women pregnant with a second child in Port Said, Egypt, manifesting in varying degrees. A range of social and obstetric factors appears to contribute to elevated levels of these psychological states. Notably, psychological capital emerged as a protective factor, demonstrating a mitigating effect on both anxiety and perceived stress and facilitating better adaptation to the physical and emotional demands of pregnancy. These results underscore the need for increased societal and familial support for pregnant women, particularly concerning enhancing their psychological resources. Furthermore, healthcare authorities should prioritize the dissemination of scientifically grounded health education to the public through: (1) integrating PCQ-24 or its short form into routine mid-pregnancy screenings to identify high risk women with low psychological capital, (2) proposing actionable interventions based on psychological capital theory (e.g., group sessions to enhance self-efficacy, optimism, and resilience), (3) explicity recommending longitudinal studies to track psychological trajectories and qualitative research to explore stressors not captured by quantitative scales.

Such efforts are essential, given the potential adverse outcomes associated with unmanaged psychological distress during pregnancy for both mothers and their infants.

Abbreviations

ANC

Antenatal Care

CS

Cesarean Section

PCQ-24

Psychological Capital Questionnaire

PRA

Pregnancy Related Anxiety

PSS

Perceived Stress Scale

PsyCap

Psychological Capital

SAS

Self-Anxiety Scale

SPSS

Statistical Package for the Social Scienes

Authors’ contributions

Conceptualization, AM andAR; Data curation, NS and AR; Formal analysis, AM, AE, KD, FN and AR; Investigation, ES, FN and AR; Methodology, A E, NS and FN; Project administration, ES; Resources, AE, ES, FN, K Dand AR; Software, NS and FN; Validation, AM and AE; Writing – original draft, AM, AE, NS, ES, FN, KD and AR; Writing – review & editing, AM, AE, KD, NS, ES, FN and AR. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported and funded by the Deanship of Scientific Research at Imam Mohammad Ibn Saud Islamic University (IMSIU) (grant number IMSIU-DDRSP2601).

Data availability

The data presented in this study are available on request from the corresponding author due to privacy restrictions.Intervention materials are freely available upon request to the corresponding author.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the current Declaration of Heliniski, and received ethical approval from the Research Ethics Committee, Faculty of Nursing, Port Said University with Code number NUR (1/5/2024)(37). Data were anonymous, therefore the recuirement for informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.