Greek validation of the Pregnancy Experience Scale–Brief (PES-Brief): psychometric evaluation of prenatal stress in pregnant women

Abstract

Background

Prenatal psychological distress may affect maternal well-being and fetal outcomes. The Pregnancy Experience Scale–Brief Version (PES-Brief) captures both positive (uplifts) and negative (hassles) experiences during pregnancy, providing insight into maternal emotional appraisal.

Design

Longitudinal observational validation study.

Aim

To translate, culturally adapt, and validate the PES-Brief in the Greek language.

Methods

A total of 156 primiparous pregnant women completed the PES-Brief at two time points: 15th–20th weeks of gestation (Phase A) and 36th–38th weeks (Phase B). Psychometric analyses were conducted using Phase A data, while Phase B data were used to explore longitudinal responsiveness. PES-Brief scores were correlated with perceived stress assessed with the Perceived Stress Scale-14 (PSS-14), and anxiety assessed with the State-Trait Anxiety Inventory (STAI-I and STAI-II). Psychometric evaluation included internal consistency, construct validity (exploratory factor analysis), and convergent validity with perceived stress and anxiety.

Results

Exploratory factor analysis supported the original two-factor structure of uplifts and hassles. PES-Brief subscale scores were significantly associated with perceived stress and anxiety, supporting convergent validity. Statistically significant changes were observed between early-to-mid and late pregnancy (Phase A and Phase B).

Conclusion

The Greek PES-Brief demonstrated satisfactory internal consistency, a clear two-factor structure, and meaningful longitudinal correlations across gestational stages. It represents a reliable tool for assessing pregnancy-related emotional experiences in research and clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08740-y.

Introduction

Stress is the natural response of an organism to internal or external stimuli that disrupts homeostasis [1]. Stressors, as factors triggering stress, may be acute or chronic, internal or external, and may arise from interpersonal, environmental, or health-related contexts, eliciting physiological and emotional adaptive responses [2]. Among all stressors, pregnancy is a distinct biopsychosocial factor characterized by physical, hormonal, and psychological changes that increase vulnerability to emotional dysregulation [3–5]. These fluctuations, particularly in the third trimester, often intensify feelings of anxiety, fear of childbirth (tokophobia), uncertainty, and occasionally, a sense of emotional detachment [6, 7].

Pregnancy is accompanied by dynamic neurohormonal activity, with the activation of the hypothalamic–pituitary–adrenal (HPA) axis as a predominant pathway that, beyond eliciting stress-related responses, can also enhance positive emotions such as joy, anticipation, and a sense of meaning. These physiological shifts often operate within the range of ‘optimal stress’ (eustasis), supporting psychological resilience and emotional balance through activation of homeostatic systems [1]. Consequently, the emotional experience of pregnancy reflects a natural coexistence of both positive and negative processes, which interact to shape the psychological profile of the expectant mother [8].

Positive pregnancy experiences (uplifts) represent an important component of maternal psychological adaptation and subjective well-being, consistent with conceptual frameworks viewing pregnancy as a period of both vulnerability and resilience [9]. Recent evidence shows that positive pregnancy experiences involve both hedonic and eudaimonic dimensions of well-being, which can attenuate the effects of prenatal stress [10].

Pregnancy-related stress is distinct and multifaceted, arising from both external pressures and internal, pregnancy-specific experiences that affect maternal adaptation and mental health. The extent to which a woman copes with these changes is influenced by individual resilience, shaped by personal resources, prenatal care, and social support [11, 12]. In particular, the presence of a supportive partner and a strong social network has been shown to buffer stress and protect maternal mental health [7].

Although not all experiences of stress are detrimental, prenatal psychological distress has been associated with adverse consequences for both mother and child, including intrauterine growth restriction, fetal distress and preterm birth, as well as postpartum depression and atypical child neurodevelopment [11, 13–15]. Mounting evidence further indicates that maternal stress may influence fetal developmental programming through biological pathways [12, 16], with potential long-term effects on cognitive, emotional, and behavioral outcomes in offspring [17–20], including disruption of the mother–infant bond [21–24].

Overall, these findings highlight the importance of timely recognition of pregnancy-related experiences, as women’s emotional and psychological adaptation during this period is shaped by the dynamic interplay of both negative and positive emotional processes. Strengthening positive emotional experiences while reducing the impact of negative pregnancy-related influences on women’s perceptions may contribute to more favorable conditions for pregnancy progression, fetal health, and infant wellbeing [25–30].

Several psychometric tools have been developed to assess pregnancy-related stress, reflecting different conceptual approaches to women’s experiences of pregnancy. Among the most widely used instruments are the Prenatal Distress Questionnaire and the Hassles Scale, which primarily focus on pregnancy-related concerns and stressors [31]. In contrast, the Pregnancy Experience Scale (PES), developed by DiPietro, conceptualizes pregnancy-related stress as a dynamic emotional appraisal that encompasses both negative (hassles) and positive (uplifts) experiences [32].

Within the Greek context, there is a lack of structured tools capable of capturing both positive and negative dimensions of women’s pregnancy experiences during this period. This limitation may reduce opportunities to identify women who could benefit from supportive care [33] and has also been associated with less optimal maternal and infant outcomes [33, 34], such as higher rates of cesarean delivery [35], difficulties in mother–infant bonding, and lower rates of successful breastfeeding [36, 37].

Therefore, this study aims to translate, culturally adapt and psychometrically validate the Greek version of the Pregnancy Experience Scale–Brief (PES-Brief), a tool capable of assessing both positive and negative emotional experiences.

Methods

Design and participants

This validation study was conducted as part of a larger prospective project at the antenatal outpatient clinic of the Elena Venizelou Maternity Hospital in Athens, Greece. The hospital has been certified as “baby-friendly” since 2011, according to the Baby-Friendly Hospital Initiative (BFHI), and adheres to the Ten Steps for Successful Breastfeeding. Participants were consecutively recruited during routine antenatal visits between February 2018 and March 2023 [38].

The study was conducted within the framework of a prospective research protocol registered at ClinicalTrials.gov (Identifier: NCT06876051; first posted on 2 September 2025) and was approved by the hospital’s Scientific Council and the Department of Quality Control and Continuing Education and was conducted in accordance with the Declaration of Helsinki and its later amendments.

Sample size adequacy was determined according to established recommendations for exploratory factor analysis, suggesting a minimum ratio of 5–10 participants per item. Given the 20-item structure of the PES-Brief and the inclusion of 156 participants at baseline, the sample size was considered adequate for psychometric evaluation.

Eligible participants were healthy low-risk primiparous women aged 18 years or older, between 15 and 20 weeks of gestation, fluent in Greek, with a normal first-trimester screening, who provided written informed consent. Exclusion criteria included multiple pregnancy, a known fetal anomaly diagnosed at the time of recruitment, a pre-existing major psychiatric disorder, or an inability to complete the questionnaires due to language or cognitive limitations. Recruitment occurred consecutively during routine antenatal outpatient visits.

Assessments were conducted at two time points: Phase A (15–20 weeks’ gestation, baseline) and Phase B (36–38 weeks’ gestation). Given the long interval between assessments and the expected psychological changes across pregnancy, Phase B data were used to explore sensitivity to change rather than test–retest reliability.

Following informed consent, 167 women were enrolled in the study. Of these, 156 completed the PES-Brief at Phase A and were included in the psychometric validation analyses. A total of 112 women also completed the Phase B assessment and were included in exploratory sensitivity-to-change analyses. Participant recruitment and retention across study phases are presented in Fig. 1.

Fig. 1.

Participant flow through recruitment and study phases. Flow diagram of participant recruitment, informed consent, and inclusion in Phase A (baseline) and Phase B assessments among primiparous pregnant women

Measures

The PSS-14 and STAI were included to examine the convergent validity of the Greek-adapted PES-Brief with established measures of perceived stress and anxiety.

The Pregnancy Experience Scale–Brief Version (PES-Brief) is a 20-item abbreviated form of the original 41-item Pregnancy Experience Scale developed by DiPietro et al. [32]. It comprises two domains—uplifts and hassles—each consisting of ten items rated for frequency and intensity on a 0–3 scale. Frequency reflects the number of items that were experienced (scores > 0), whereas intensity represents the mean emotional impact of endorsed items, calculated by dividing the sum of their intensity ratings by the corresponding frequency. Two additional indices, the hassles-to-uplifts frequency and intensity ratios, capture the balance between negative and positive experiences, with values > 1 indicating predominance of negative experiences. The original PES demonstrated adequate internal consistency (Cronbach’s α = 0.71–0.86 across subscales) and evidence of construct and convergent validity.

The brief version preserves the conceptual structure and psychometric properties of the original scale while reducing respondent burden. Importantly, neither hassles nor uplifts are assumed to have a fixed emotional valence; rather, their appraisal is captured through each woman’s subjective ratings of frequency and intensity.

The Perceived Stress Scale (PSS-14), developed by Cohen et al. was designed to assess levels of perceived stress over the past month. It consists of 14 items rated on a 0–4 scale and the total score ranges from 0 to 56. Higher scores indicate greater perceived stress. The original version demonstrated good internal consistency (Cronbach’s α ≈ 0.84–0.86) and construct validity [39] and has been widely used in studies involving pregnant women [40, 41]. The PSS-14 has been validated in the Greek language and has demonstrated satisfactory reliability and construct validity in adult populations [42, 43]. The PSS-14 was analysed as a continuous measure. For descriptive purposes, the proportion of women scoring ≥ 25 on the PSS-14 was additionally examined, as this value approximates the mean score reported in Greek adult samples, to facilitate sample characterization and to explore differences in pregnancy-related experiences according to perceived stress levels.

The State–Trait Anxiety Inventory (STAI) was developed by Spielberger et al. (1970) to assess two dimensions of anxiety: transient, situation-dependent anxiety (State; STAI-I) and more stable, longer-term patterns of anxiety (Trait; STAI-II). Each subscale consists of 20 items rated on a 1–4 scale, yielding total scores ranging from 20 to 80, with higher scores indicating higher anxiety [44]. The instrument demonstrates excellent reliability (typically α > 0.90) and strong construct validity across clinical and non-clinical populations and is widely used in studies of pregnant women [45, 46]. The STAI has been standardized in the Greek language and has demonstrated satisfactory reliability and normative score ranges for anxiety assessment in clinical practice [47].

Translation and cultural adaptation

The PES-Brief was translated and culturally adapted into Greek following internationally recommended guidelines for instrument translation and cultural adaptation [48, 49].

A forward translation was conducted by a bilingual neonatologist, and a backward translation by an independent bilingual psychologist, both experienced in perinatal mental health terminology.

The original and back-translated English versions were compared in detail, and discrepancies were resolved through consensus to ensure semantic and conceptual equivalence. Particular attention was paid to the interpretation of “uplifts” and “hassles” within the Greek cultural context. The final Greek version was approved by the research team.

A pilot administration with 10 pregnant women was conducted to assess clarity and comprehensibility. Minor guidance was required prior to completion, mainly to clarify the grouping of items into “uplifts” and “hassles,” despite the clarity of the section titles, and to ensure consistent understanding of a few terms. Participant feedback served as informal cognitive debriefing. No modifications to the content or structure of the instrument were deemed necessary.

Statistical analysis

Statistical analyses were conducted to evaluate the construct validity, internal consistency, convergent validity, and sensitivity to change of the PES-Brief. Quantitative variables were summarized as means and standard deviations, while categorical variables were expressed as absolute and relative frequencies. Psychometric validation analyses (construct validity, internal consistency, and convergent validity) were performed exclusively using Phase A data, whereas Phase B data were used solely to examine sensitivity to change over time.

Construct validity was examined using Exploratory Factor Analysis (EFA). Principal axis factoring was selected as the extraction method, with Oblimin rotation to allow for correlations between factors. Standard methodological criteria for factor analysis were applied, including evaluation of sampling adequacy, factor retention, and interpretability of the factor structure. Sample size adequacy was determined a priori based on established recommendations suggesting a minimum subject-to-item ratio of 5–10 participants per item [50]. Given the 20-item structure of the PES-Brief, the available sample size was considered adequate for factor analytic procedures.

Sampling adequacy was assessed using the Kaiser–Meyer–Olkin (KMO) statistic, and Bartlett’s test of sphericity was used to confirm factorability. Factors with eigenvalues > 1 and item loadings ≥ 0.40 were retained. KMO and Bartlett’s tests were examined separately for the hassles and uplifts subscales and indicated sampling adequacy. Item communalities were also inspected and found to be acceptable.

Internal consistency was evaluated using both Cronbach’s alpha and McDonald’s omega coefficients. Cronbach’s alpha assessed the conventional homogeneity of each subscale, whereas McDonald’s omega accounted for variability in item loadings and provided a more robust estimate of internal consistency. Values ≥ 0.70 were considered acceptable.

Convergent validity was assessed using Spearman’s correlation coefficients between PES-Brief subscales and two validated Greek-language instruments administered at Phase A: the Perceived Stress Scale (PSS-14) [43] and the State–Trait Anxiety Inventory (STAI-I and STAI-II) [47]. The aim was to determine whether the PES-Brief correlates as expected with established measures of perceived stress and anxiety.

Spearman’s rank correlation coefficient (ρ) was used to assess the strength and direction of monotonic associations with values ranging from − 1 (perfect negative correlation) to + 1 (perfect positive correlation).

To contextualize perceived stress levels within the sample, PSS-14 scores were interpreted in relation to mean values reported in previous Greek studies conducted in healthy adult populations [43]. A value of 25, approximating the reported normative mean, was used as an exploratory descriptive reference point to facilitate within-sample comparisons rather than as a clinical threshold.

Sensitivity to change was examined by comparing PES-Brief scores between Phase A and Phase B. As subscale scores did not meet normality assumptions, non-parametric tests (Wilcoxon signed rank) were applied to evaluate changes over time. Effect sizes were calculated as r = Z/√N and interpreted according to Cohen’s criteria (0.10 = small, 0.30 = moderate, ≥ 0.50 = large) [51]. Additionally, Spearman’s correlation coefficients were used to evaluate the consistency of individual score rankings across time point assessments. All tests were two-tailed, with statistical significance set at p < .05. Analyses were conducted using IBM SPSS Statistics, version 26.0 (Armonk, NY, USA).

Results

Of the 164 women enrolled in the study, 156 completed the PES-Brief at baseline (Phase A) and were included in the psychometric analyses. The mean (SD) age of participants was 34.1 (4.8) years. The mean (SD) gestational weight gain was 12.2 (5.2) kg and the mean (SD) pre-pregnancy BMI was 23.1 (4.2) kg/m². Most participants were married (71.8%), 44.5% were university graduates, and 92.3% were non-smokers. Demographic characteristics are summarized in Table 1.

Table 1.

Demographic characteristics of the study participants (N = 156). Continuous variables are presented as mean (SD), and categorical variables as Ν (%)

Demographics of women (Ν = 156)		Mean	SD
Age (years)		34.1	4.8
Years of education beyond High school		5.4	2.9
BMI (kg/m2) before pregnancy		23.1	4.2

		Ν	%
Marital status	Single	44	28.2
	Married	112	71.8
Parity	primiparous	156	100
Current Smoking	Yes	11	7.1
	No	144	92.9

Percentages may not sum to 100% due to missing data; SD standard deviation, N number of participants

Descriptive analysis of the PSS-14 data showed that among women who completed the questionnaire, the mean (median) total score was 21.69 (22) in Phase A and 20.68 (20) at Phase B.

For state anxiety (STAI-I), mean (median) scores were 49.3 (50) at Phase A and 49.2 (50) at Phase B. For trait anxiety (STAI-II), mean (median) scores were 45.9 (45) at Phase A and 44.29 (42.5) at Phase B.

Item-level descriptive statistics for the Greek-adapted PES-Brief are presented in Table 2, summarizing responses to individual pregnancy-related experiences across the Uplifts and Hassles domains.

Table 2.

Descriptive statistics for Greek-adapted PES-Brief items (N = 156), including uplifts and hassles domains

	%	Mean	SD
Uplifts
1. How much the baby is moving	92.9	2.42	0.89
2. Discussions with spouses about baby names	89.7	1.83	1.00
3. Comments from others about your pregnancy/appearance	93.6	1.92	0.85
4. Making or thinking about nursery arrangements	66.7	1.13	1.02
5. Feelings about being pregnant at this time	99.4	2.55	0.65
6. Visits to obstetrician / midwife	98.7	2.40	0.67
7. Metaphysical feelings about being pregnant	73.7	1.17	0.96
8. Courtesy/assistance from others because you are pregnant	87.8	1.87	0.99
9. Thinking about the baby’s appearance	97.4	2.40	0.77
10. Discussions with spouses about pregnancy/childbirth issues	98.7	2.38	0.75
Hassles
1. Getting enough sleep	43.6	0.65	0.87
2. Physical attraction	59.0	0.87	0.91
3. Normal discomforts of pregnancy (heartburn, incontinence)	75.6	1.12	0.88
4. Your weight	71.8	1.09	0.91
5. Body changes due to pregnancy	66.7	0.87	0.78
6. Thoughts about whether the baby is normal	91.0	1.80	0.95
7. Thinking about your labor and delivery	81.4	1.46	0.97
8. Ability to do physical tasks / chores	63.5	0.92	0.85
9. Concerns about physical symptoms (pain, spotting, etc.)	80.8	1.23	0.89
10. Clothes / shoes don’t fit	48.4	0.68	0.83

Percentages indicate the proportion of participants reporting each experience (score ≥ 1); PES-Brief  Pregnancy Experience Scale–Brief Version, M mean, SD standard deviation

Among uplifts, the most frequently endorsed item was “Feelings about being pregnant at this stage of pregnancy” (99.4%), which also showed the highest mean score (M = 2.55, SD = 0.65), underscoring its central emotional importance. Other frequently reported uplifts included “Visits to the obstetrician/midwife” and “Discussions with spouse about pregnancy or childbirth issues” (both 98.7%). The lowest mean uplift score was observed for “Making or thinking about nursery arrangements” (M = 1.13, SD = 1.02).

Among hassles, “Thoughts about whether the baby is normal” was the most frequently endorsed (91%) and had the highest mean score (M = 1.80, SD = 0.95), while “Clothes/shoes don’t fit” had the lowest (M = 0.68, SD = 0.83).

Overall, uplifts were reported more frequently (66.7%–99.4%) and with higher mean intensity scores (1.13–2.55) than hassles (endorsement range: 43.6%–91%; mean scores: 0.65–1.80), suggesting that participants generally experienced more positive than negative feelings related to pregnancy.

Exploratory factor analysis (principal axis factoring with oblimin rotation) revealed a two-factor structure accounting for 39.2% of the total variance (Supplementary Table S1). The KMO value was 0.79 and Bartlett’s test was significant (p < .001), indicating adequacy for factor analysis and the inter-item correlations. Specifically, the first factor (hassles) explained 22.6% and the second (uplifts) 16.6% of the variance. All items showed loadings > 0.40 on their respective factors, consistent with the theoretical structure of the PES-Brief.

Internal consistency reliability was assessed using Cronbach’s alpha and McDonald’s omega coefficients, both of which exceeded the conventional threshold of 0.70. For the uplifts subscale, α = 0.77 and ω = 0.78; for the hassles subscale, α = 0.84 and ω = 0.84, indicating satisfactory internal consistency. Item-total correlations for both subscales were above 0.30, and the deletion of any item did not result in a substantial decrease in internal consistency. Detailed reliability indices are presented in Supplementary Table S2.

To assess convergent validity, Spearman correlation analyses were conducted between PES-Brief subscales and measures of perceived stress (PSS-14) and State and Trait Anxiety (STAI-I and STAI-II), as presented in Table 3. The PES-Brief demonstrated statistically significant associations with perceived stress and anxiety measures at Phase A, with hassles and hassles-to-uplifts ratios showing the strongest and most consistent correlations.

Table 3.

Spearman’s rank correlations of PES-Brief frequency, intensity, and ratio scores with measures of perceived stress (PSS-14 ) and state and trait anxiety (STAI -I, STAI-II) at Phase A

			Frequency Uplifts	Intensity Uplifts	Frequency Hassles	Intensity Hassles	Hass / Ups Frequency Ratio	Hass / Ups Intensity Ratio
	Mean (SD)
PSS-14 score	21.59 (8.18)	rho	-0.03	-0.23	0.47	0.38	0.45	0.44
		p	0.74	< 0.01	< 0.001	< 0.001	< 0.001	< 0.001
State (STAI -I)	34.33 (9.19)	rho	-0.01	-0.25	0.38	0.29	0.32	0.35
		p	0.90	< 0.01	< 0.001	< 0.001	< 0.001	< 0.001
Trait (STAI-II)	37.40 (9.96)	rho	0.08	-0.21	0.37	0.35	0.34	0.38
		p	0.31	< 0.05	< 0.001	< 0.001	< 0.001	< 0.001

PSS – 14 Perceived Stress Scale-14, STAI State–Trait Anxiety Inventory, Phase A: 15–20 weeks of gestation; Hass / Ups: hassles / uplifts; rho (ρ): Spearman’s rank correlation coefficient; p: significance level. Values of p are reported as exact values when p ≥ .05 and as thresholds when p < .05

Specifically, uplift intensity - rather than frequency - showed more consistent and significant negative correlations with both perceived stress and anxiety.

In contrast, the frequency and intensity of hassles, as well as both the frequency and intensity ratios of hassles to uplifts, were positively and significantly associated with higher levels of stress and anxiety. These findings are consistent with the convergent validity of the PES-Brief.

PES-Brief subscale scores further compared between women with elevated perceived stress (PSS-14 ≥ 25) and those scoring below this threshold at Phase A (Table 4). Women with elevated stress (n = 53) reported lower uplift intensity [median (IQR): 2.11 (1.78–2.40) vs. 2.30 (2.00–2.60)], higher hassle frequency [9.0 (7.0–10.0) vs. 6.0 (5.0–8.0)] and higher hassle intensity [1.70 (1.40–2.00) vs. 1.29 (1.11–1.67)], compared to women with lower perceived stress. In addition, higher hassles-to-uplifts ratios for both frequency [0.90 (0.80–1.11) vs. 0.70 (0.50–0.90)] and intensity [0.77 (0.67–0.98) vs. 0.61 (0.47–0.77)] was observed.

Table 4.

PES -Brief frequency, intensity, and hassles-to-uplifts ratio scores at phase A stratified by elevated perceived stress (PSS-14 ≥ 25)

	PSS-14 < 25 (n = 103)	PSS-14 ≥ 25 (n = 53)
	Median (IQR)	Median (IQR)	p
Frequency Uplifts	9.0 (9.0 ─ 10.0)	9.0 (8.0 ─ 10.0)	0.264
Intensity Uplifts	2.3 (2.0 ─ 2.6)	2.11 (1.78 ─ 2.4)	< 0.05
Frequency Hassles	6.0 (5.0 ─ 8.0)	9.0 (7.0 ─ 10)	< 0.001
Intensity Hassles	1.29 (1.11 ─ 1.67)	1.7 (1.4 ─ 2.0)	< 0.01
Hass/Ups Frequency Ratio	0.7 (0.5 ─ 0.9)	0.9 (0.8 ─ 1.11)	< 0.001
Hass/Ups Intensity Ratio	0.61 (0.47 ─ 0.77)	0.77 (0.67 ─ 0.98)	< 0.001

Phase A: 15–20 weeks of gestation; Phase B: 36–38 weeks of gestation; PSS-14: Perceived Stress Scale-14; SD Standard Deviation, ΙQR Interquartile Range, p significance level, Hass/Ups Hassles/ Uplifts

Data from 112 women who completed Phase B were used to examine sensitivity to change. Descriptive statistics for PES-Brief scores across phases are presented in Table 5.

Table 5.

Comparison of PES-Brief subscale and ratio scores between phase A (baseline) and phase B (follow-up) using Wilcoxon signed-rank tests

	Phase A	Phase B	p	Effect size
	Median (IQR)	Median (IQR)
Frequency Uplifts	9 (8 ─ 10)	9 (9 ─ 10)	0.081	0.16
Intensity Uplifts	2.22 (2 ─ 2.5)	2.3 (2 ─ 2.6)	< 0.05	0.23
Frequency Hassles	7 (5 ─ 9)	7 (5 ─ 9)	0.597	0.05
Intensity Hassles	1.44 (1.15 ─ 1.78)	1.33 (1.14 ─ 1.67)	< 0.05	0.21
Hassles/Uplifts Frequency Ratio	0.78 (0.53 ─ 1)	0.78 (0.53 ─ 1)	0.710	0.04
Hassles/Uplifts Intensity Ratio	0.67 (0.53 ─ 0.84)	0.63 (0.48 ─ 0.77)	< 0.001	0.30

Phase A: 15–20th weeks of gestation; Phase B: 36–38 weeks of gestation; IQR interquartile range, SD standard deviation; p significance level derived from Wilcoxon signed rank test; effect size: calculated for Wilcoxon signed-rank tests (small ≈ 0.10, moderate ≈ 0.30)

Wilcoxon signed-rank tests indicated a significant increase in uplift intensity and significant decreases in hassle intensity and the hassles-to-uplifts intensity ratio from Phase A to Phase B (p < .05). The significant observed differences were associated with small to moderate effect sizes (r ranged from 0.21 to 0.30) (Table 5).

Spearman’s correlation analyses between Phase A and Phase B scores showed significant positive associations across all PES-Brief subscales (Table 6). Uplift frequency showed a low-to-moderate correlation (rho = 0.27, p = .004), while uplift intensity yielded a moderate-to-strong correlation (rho = 0.49, p < .001). Hassle frequency and intensity also showed moderate-to-strong correlations (rho = 0.56 and 0.49, respectively, both p < .001). Similarly, the hassles-to-uplifts frequency and intensity ratios demonstrated strong and moderate-to-strong correlations (rho = 0.57 and 0.49, respectively, p < .001).

Table 6.

Spearman correlation coefficients (rho(ρ)) between PES -Brief subscale scores at phase A and phase B

		Frequency	Intensity
Uplifts	rho(ρ)	0.27	0.49
	p	< 0.01	< 0.001
Hassles	rho(ρ)	0.56	0.49
	p	p < .001	< 0.001
Hassles / Uplifts Ratio	rho(ρ)	0.57	0.49
	p	p < .001	p < .001

PES-Brief Pregnancy Experience Scale–Brief Version; Phase A: 15–20 weeks of gestation; Phase B: 36 − 38 weeks of gestation; p: significance level; rho (ρ): Spearman’s rank correlation coefficient. Values of p are reported as exact values when p ≥ .05 and as thresholds when p < .05

Discussion

The present study aimed to translate, culturally adapt, and evaluate the psychometric properties of the Pregnancy Experience Scale–Brief Version (PES-Brief) in a Greek sample of pregnant women. Overall, findings support the reliability, validity, and conceptual coherence of the Greek PES-Brief. This is evidenced by a stable two-factor structure and satisfactory internal consistency. In addition, the scale showed the expected associations with established measures of perceived stress and anxiety. Longitudinal analyses further indicated that the PES-Brief is sensitive to changes in emotional experiences across pregnancy, supporting its capacity to capture dynamic aspects of pregnancy-related affect.

During the translation and application of the PES-Brief, several linguistic and cultural challenges emerged, particularly in relation to items that lacked direct equivalents in the Greek language. Only a small number of items required conceptual clarification, informed by participant feedback during cognitive debriefing and consultation with the scale developer, while no items were structurally modified.

Although the terms “uplifts” and “hassles” do not correspond to single, direct linguistic equivalents in Greek, their meaning is sufficiently clarified within the instrument itself through the introductory instructions provided prior to each set of items.

To ensure conceptual equivalence, further clarification was sought from the original author of the PES-Brief for two specific items. According to the scale developer, the 7th item of the uplifts subscale (“Spiritual feelings about being pregnant at this stage of pregnancy”) is intentionally broad, allowing for both religious and non-religious interpretations. The Greek wording was therefore selected to preserve this openness and avoid restricting the interpretation to a single conceptual domain, while maintaining the intended meaning of the original scale.

A similar challenge arose for the 2nd item of the hassles subscale (“physical intimacy”), which initially posed difficulties during translation. Further clarification was sought from the original developer of the PES-Brief to ensure conceptual equivalence. The final interpretation incorporated the dimension of “sexual or physical attraction,” which more accurately reflects the original intent of the item. Importantly, these adaptations did not constitute item modification but represented conceptual paraphrasing, aiming to preserve semantic equivalence while enhancing cultural comprehensibility.

The items most frequently endorsed as positive experiences were “feelings about being pregnant at this time,” “visits to the obstetrician,” and “discussions with the partner about baby issues.” This pattern may reflect a strong reliance of Greek pregnant women on healthcare professionals, particularly in relation to medical monitoring, as well as a pronounced emphasis on partner communication [52–57].

This finding is likely related to timing, as the lower rating of the pleasure associated with fetal movements may reflect the timing of questionnaire administration in the early second trimester. During this period, fetal movements are often subtle or not yet consistently perceived [58, 59].

With regard to hassles, concerns about whether the baby is normal emerged as a prominent theme, reflecting heightened awareness of fetal health and an accompanying sense of uncertainty regarding pregnancy outcome [59, 60]. In contrast, concerns related to changes in physical appearance appeared to be of lesser importance.

Additionally, the increased prominence of uplifts and the reduced impact of hassles observed at the later assessment demonstrate the PES-Brief’s sensitivity to changes in maternal emotional experiences across pregnancy [61, 62]. The longitudinal analyses were exploratory in nature and focused on observed changes in PES-Brief scores across pregnancy, without implying causal or developmental interpretations. Moreover, the significant associations observed between the PES-Brief subscales and established measures of perceived stress and anxiety (PSS-14, STAI-I/II) further support the convergent validity of the instrument, confirming its capacity to capture emotional dimensions relevant to prenatal stress.

In the present sample, State and Trait anxiety scores remained elevated across pregnancy. Although these values do not indicate clinical diagnoses, they are comparable to levels frequently reported in perinatal populations, where STAI scores above 40 are commonly used to denote heightened anxiety [63, 64].

Notably, in early-to-mid gestation, higher perceived stress was associated with lower intensity of positive experiences among women, whereas toward the end of pregnancy it appeared to be primarily related to a higher frequency of negative experiences. These findings suggest that perceived stress may be accompanied by a differentiated emotional processing of pregnancy-related experiences. Elevated stress may be associated with increased emotional reactivity or a lower tolerance threshold toward everyday pregnancy-related challenges, which could help explain the more frequent reporting of negative experiences, reflecting broader patterns of psychological vulnerability during the perinatal period [65–67].

The PES-Brief has been translated into several languages, with multiple published validation studies available to date [52–57, 68, 69]. Collectively, these studies support the scale’s cross-cultural applicability, consistently demonstrating its capacity to capture key emotional dimensions of pregnancy. The present Greek validation adds further evidence and provides a reliable tool for both clinical and research use within the local context. Inspection of factor loadings indicated clear item clustering, with all items loading strongly on a single factor per subscale and no meaningful cross-loadings observed. This data-driven pattern supported the retention of a two-factor solution corresponding to hassles and uplifts, consistent with previous international validations [52–56]. Although the two-factor solution accounted for a modest proportion of the total variance (39.2%), this level of explained variance is comparable to that reported in other brief psychosocial instruments and may partly reflect cultural nuances or the brevity of the scale.

The hassles-to-uplifts scoring ratios in the Greek sample were highly comparable to those reported in the original U.S. validation by DiPietro [56], where ratios were similarly below 0.70, reinforcing the view of pregnancy as a predominantly positive life experience. In contrast, higher ratios have been reported in other cultural settings [53], suggesting that cultural context may shape how pregnancy-related experiences are perceived and evaluated.

Within this perspective, the PES-Brief is not intended as a diagnostic instrument but rather as a brief screening and monitoring tool of emotional balance during pregnancy. No clinical cut-off scores are currently established for the scale. Nevertheless, the relative balance between hassles and uplifts, as well as changes in these dimensions over time, may provide clinically meaningful information regarding maternal emotional burden. Elevated hassles, reduced uplifts, or marked shifts across pregnancy may signal the need for closer monitoring or further assessment using established clinical evaluation tools.

Limitations

Several limitations should be acknowledged. First, the PES-Brief was administered in early-to- mid gestation (15–20 weeks), when certain pregnancy-related experiences (e.g., fetal movements) may not yet have emerged; additionally, as all participants were primiparous, some responses may have reflected expectations rather than lived experiences. Moreover, the exclusive recruitment of primiparous, low-risk women from a baby-friendly hospital setting, with a relatively high mean maternal age and a high educational level of the participants, may limit the generalizability of the findings. Consequently, the psychometric performance of the Greek PES-Brief may differ in women with high-risk pregnancies, multiparous women, or those from more diverse socioeconomic and clinical backgrounds, and should be examined in future validation studies.

Second, although data were collected at two time points, the long interval between Phase A and Phase B assessments, during which substantial pregnancy-related psychological changes are expected, precluded formal test–retest reliability analysis. Sensitivity-to-change findings should be interpreted with caution, as Phase B assessments were conducted within the context of a broader clinical protocol that included a stress-management intervention; therefore, observed score changes may not exclusively reflect naturalistic emotional fluctuations across pregnancy. Nevertheless, these analyses provide preliminary evidence of the PES-Brief’s responsiveness to changes in maternal emotional experiences, irrespective of their underlying source.

Measurement invariance across time points (e.g., using multi-group confirmatory factor analysis) was not examined. The study design did not include a formal longitudinal psychometric framework. Furthermore, not all participants who completed Phase A were retained at Phase B, resulting in an attrition rate of approximately 28% due to non-completion of questionnaires and obstetric events (Fig. 1). The possibility of systematic attrition cannot be fully excluded and should be considered when interpreting sensitivity-to-change findings.

Third, recruitment challenges related to demographic trends, population heterogeneity, and COVID-19 extended the data collection period; however, the final sample size remained adequate for psychometric analyses.

Finally, as this study represents the initial linguistic and cultural validation of the PES-Brief, exploratory factor analysis was considered appropriate. Confirmatory factor analysis was not performed due to sample size considerations, and confirmation of the factor structure should be addressed in future studies with larger Greek samples.

Conclusions

Pregnancy is a multifactorial and dynamic biopsychosocial process in which emotional experiences may include both positive and negative dimensions. The PES-Brief provides a structured approach for describing these experiences by simultaneously capturing pregnancy-related hassles and uplifts, allowing a nuanced representation of emotional experiences during pregnancy.

The present findings support the validity and internal consistency of the Greek version of the PES-Brief and confirm its underlying two-factor structure, in line with previous international validation studies. The successful cultural adaptation of the instrument indicates that its conceptual framework is retained within the Greek cultural context.

While the PES-Brief is not a diagnostic tool, it may support the structured documentation of areas of emotional strain and positive coping during pregnancy, which can be relevant for research and psychosocial understanding in prenatal care contexts.

Authors’ contributions

Dr. A.F.: Principal Investigator, Conceptualization, Study Design, Data Collection, Interpretation, Drafting the manuscript and Editing. Dr. S. P.: Revision and Editing of the manuscript. Prof. P. P.: Critical Revision of the manuscript, Prof. emeritus G. C.: Academic senior supervision. Prof T. S.: Study Design, Overall Supervision, Critical Revision of the manuscript, guidance on Journal Selection. All authors read and approved of the final manuscript.

Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors. The costs of statistical analysis and publication were covered personally by the first author.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Scientific Council and the Department of Quality Control and Continuing Education of the General and Maternity Hospital “Elena Venizelou” (Athens, Greece) and was conducted in accordance with the Declaration of Helsinki and its later amendments. All participants provided written informed consent prior to enrollment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.