Abstract
Objectives
Pregnancy can be a positive yet stressful experience due to various changes. Perceived risks from natural disasters like earthquakes may negatively affect pregnant women’s mental health, disrupting sleep and heightening fear and anxiety during labor. Poor sleep quality can lead to complications, gestational diabetes, preterm labor, and low birth weight in newborns. This study examined the relationship between earthquake risk perception and sleep problems in pregnant women.
Methods
This descriptive-correlational study was conducted from October to December 2023 with 303 pregnant women in two hospitals in Turkey’s Central Black Sea Region. Data were collected using a “Personal Information Form,” “Earthquake Risk Perception Scale,” and “Sleep Problems Scale for Pregnant Women”. Analyses were performed with IBM SPSS 20.0. As the data were not normally distributed, non-parametric tests were used: Mann–Whitney U for two-group comparisons, Kruskal–Wallis for multiple groups, and Spearman correlation to examine relationships between variables. p < 0.05 was considered statistically significant.
Results
In the study, 42% of pregnant women were in their first pregnancy, 97.7% had not experienced a major disaster. A significant relationship was found between earthquake risk perception and problems (p = 0.000; r = 0.246).
Conclusion
A significant relationship exists between earthquake risk perception and sleep problems in pregnant women. Health professionals should enhance awareness and provide support to promote positive risk perception among them.
Keywords: Earthquake risk perception, Earthquake, Pregnancy, Sleep
Contributions to the literature
Studies on the relationship between earthquake risk perception and sleep problems in pregnant women living in countries with 1st degree earthquake risk are limited.
Natural disasters such as earthquakes negatively affect groups such as pregnant women, women, children, the elderly and the disabled more physically and psychologically.
Although sleep problems are common in pregnant women, the risk of experiencing an earthquake that creates intense stress can affect this situation even more negatively.
Background
Although pregnancy is usually associated with positive emotions, it can also be experienced as a stressful life event as it involves physical, psychological and social changes [1]. While pregnancy is an exciting time, it also carries risks for both mother and baby, causing anxiety. These risks may stem from the mother, the baby, or external factors [2, 3]. In this highly complex process, exposure of pregnant women to situations such as natural disasters affect their mental health negatively [1, 4]. Especially the fact that they have witnessed a major earthquake in the past may trigger their risk perception and concerns about earthquakes [5].
Earthquake is a natural event that can directly affect individual and social life and is difficult to predict in advance [6]. Turkey, situated within the Alpine-Himalayan fold belt, lies predominantly in an earthquake-prone zone. The region experiences constant compression as the Eurasian Plate to the north and the African Plate to the south exert pressure, reflecting Anatolia’s incomplete geological evolution [7]. There is always the possibility of a destructive earthquake in Turkey. Indeed, one of the indicators of this is the Kahramanmaraş-based earthquakes (http://www.hiasd.org/6-subat-2023-kahramanmaras-depremi-afet-yonetimi-degerlendirmeleri). On February 6, 2023, a magnitude 7.8 earthquake struck southeastern Turkey, followed by a second earthquake with a magnitude of 7.5. The disaster caused widespread loss of life, destruction, and devastation. It also had a significant psychological impact on survivors and individuals living in earthquake-prone areas throughout Turkey [8]. Earthquake is a process full of risks, dangers and uncertainties. Earthquakes, which are an unobservable and unpredictable hazard, may affect the risk perception of individuals believing that they may be harmed in general, while risk perception affects the emotions and behaviours of individuals [9–12]. Risk perception plays an important role in the behavioural process, individuals can perceive the risk positively and take the situation under control, or they can be harmed by not managing their risk perception effectively [13]. A large number of studies conducted worldwide on different types of disasters have indicated that women, especially pregnant women, have a high perception of risk [14–16]. Risk perception is an emotional process and its results are similarly seen in emotional parameters. Various studies have found that a woman’s high-risk perception during pregnancy increases the level of anxiety [17, 18]. High-risk perception makes it difficult for women to adapt to pregnancy and affects pregnancy negatively. On the other hand, the first reaction of the human body in the presence of unfavorable situations is the change in sleep habits. Regardless of the reason, even the smallest fluctuation in the mental health of individuals manifests itself through changes in sleep routines [19]. Sleep is a fundamental physiological necessity for human survival. Quality sleep plays a vital role in relieving physical and mental fatigue, supporting immune system regulation, and promoting overall physical and mental well-being [20]. Life-threatening situations raise cortisol and adrenaline levels in pregnant women, while lowering dopamine and serotonin. Environmental distress similarly increases maternal cortisol, disrupting sleep patterns and quality [21]. Without an earthquake, major depressive disorders affect 7–15% of pregnant and postpartum women, but natural disasters like earthquakes raise this rate, harming both maternal and infant health [22]. There are studies in the literature that show that the psychological reactions of pregnant women to earthquakes negatively affect them and their babies and lead to consequences such as suicide and premature birth [23, 24]. It is also thought that poor sleep quality during pregnancy may lead to increased fear and anxiety during labor, stress, prolonged labor, development of complications, increased gestational diabetes and glucose intolerance, preterm labour, newborns with low birth weight and developmental problems [25]. Therefore, considering all these, it is inevitable for earthquakes, among the most stressful events, to directly affect pregnant women’s risk perception and sleep quality.
There are various studies in the literature on risk perception and sleep problems in pregnant women. These studies have been discussed within the scope of risk perception of pregnancy or sleep problems [18, 26]. However, no studies were found evaluating risk perception of earthquake and sleep disorders together in pregnant women. The aim of this study was to determine the relationship between earthquake risk perception and sleep problems in pregnant women.
Methods
Study design
This research has a descriptive and correlational design.
Place and time of research
The study was conducted on pregnant women living in the cities of Erbaa and Turhal, which are located in the Central Black Sea Region of Turkey and also in a region with a first-degree earthquake risk on the North Anatolian Fault Zone of Turkey. The study was carried out with pregnant women who presented to the Obstetrics and Gynaecology Outpatient Clinics and who were hospitalised in the Obstetrics and Gynaecology Services of Erbaa and Turhal State Hospitals. The data of the study were collected between October and December 2023.
Sample and data collection
The high probability of the pregnant women to encounter an earthquake was decisive in the selection of the sample group from the cities mentioned above. Population of the study consisted of pregnant women who presented to the Obstetrics and Gynaecology Outpatient Clinics and who were hospitalised in the Obstetrics and Gynaecology Services of the relevant hospitals. The minimum sample size for the study was determined using G*Power version 3.1.9.7. An a priori power analysis was conducted for a bivariate correlation model with a two-tailed test. Effect sizes and their 95% confidence intervals were calculated to assess the precision of the estimates. Based on a medium effect size (r = 0.30), a significance level (α) of 0.05, and a statistical power (1 − β) of 0.95, the analysis indicated that at least 138 participants were required to detect potential associations between variables. Although the minimum required sample size was 138, a total of 320 pregnant women were contacted during the study period. Of these, 11 declined to participate and 6 were excluded due to incomplete data. Consequently, the study was completed with 303 pregnant women. In the study and pregnant women who were over 18 years of age, who could establish healthy communication and who volunteered to participate in the study were included in the study. The data were collected through face-to-face interviews by the researchers using the following data collection tools.
Measures
Personal information form
This form, which was prepared by the researchers in the light of the literature, includes a total of 13 questions that can determine the socio-demographic, obstetric and earthquake-related characteristics of pregnant women [27–29].
Earthquake Risk Perception Scale
It was developed by Trumbo et al. in 2016. The scale aims to determine hurricane risk perception from an affective (items 1, 2, 3 and 4) and cognitive (items 5, 6, 7 and 8) perspective. The questions related to affective risk perception reflect mood disorders such as fear, anxiety, terror and depression caused by the natural disaster. Therefore, affective risk perception is related to how the natural disaster makes the person feel. Questions related to cognitive risk perception, on the other hand, reflect the perception of the individual about the natural disaster causing disaster, death, financial problems and danger for future generations. In other words, cognitive risk perception expresses the meaning and interpretation of the natural disaster for the person. When the scale is intended to be used in another type of natural disaster, it has been suggested to be used only by changing the name of the disaster [30]. In 2021, Mızrak et al. conducted the Turkish validity and reliability of the scale and modified it according to the ‘earthquake’ disaster. For example, the statement ‘Hurricane worries me’ was changed to ‘Earthquake worries me’. The scale is a 5-point Likert-type scale (1 = Disagree, 2 = Disagree, 3 = Moderately Agree, 4 = Agree, 5 = Strongly Agree) and consists of a total of 8 items scored between 1 and 5. A minimum score of 8 and a maximum score of 40 can be obtained from the scale, which is evaluated on a total score [31]. Cronbach’s alpha coefficient was 0.857 in the adaptation study and 0.853 in the present study.
Sleep Problems Scale for Pregnant Women (SPS-PW)
The scale developed by Gökdemir and Yılmaz consists of 24 items and four sub-dimensions. The “Sleep Problems Due to Physical Symptoms During Pregnancy” sub-dimension includes ten items; the “Sleep Problems Due to Changes in Sleep-Wake Cycle” sub-dimension includes seven items; the “Sleep Problems Due to Deterioration in Sleep Quality During Pregnancy” sub-dimension includes four items; and the “Sleep Problems Due to Respiratory System During Pregnancy” sub-dimension includes three items. The scale uses a five-point Likert format scored from 1 to 5. The items 1, 2 and 3 are reversely scored. The lowest possible score is 24 points and the highest possible score is 120 points. A higher score on the scale indicates that the pregnant woman has more sleep problems [32]. Cronbach’s alpha coefficient of the scale was 0.783 in Gökdemir and Yılmaz’s study and 0.882 in the present study.
Data analysis
The data were analysed in IBM SPSS 20.0 programme. Since the data did not show normal distribution, nonparametric tests were used in the analysis. Mann-Whitney U test was used to compare two independent groups and Kruskal-Wallis test was used to compare more than two independent groups. Correlations were calculated by Spearman rank correlation. A value of p < 0.05 was considered statistically significant.
Results
General characteristics
The distribution of pregnant women according to their socio-demographic, obstetric and earthquake-related characteristics is shown in Table 1.
Table 1.
Distribution of Pregnant Women According to Socio-Demographic, Obstetric and Earthquake-Related Characteristics
| Variables (N = 303) | ||
|---|---|---|
| Mean ± SD | Min-Max | |
| Age (Years) | 25 ± 3.247 | 18–35 |
| Age at First Pregnancy | 22 ± 2.697 | 18–31 |
| n | % | |
|---|---|---|
| Number of Births | ||
| 0 (First pregnancy) | 129 | 42.6 |
| 1 | 109 | 36.0 |
| 2 | 48 | 15.8 |
| 3 | 16 | 5.3 |
| 4 | 1 | 0.3 |
| Current Gestational Week | ||
| < 13 | 56 | 18.5 |
| 13–27 | 74 | 24.4 |
| ≥ 27 | 173 | 57.1 |
| Presence of Adverse Situation Related to Previous Pregnancy | ||
| Yes | 9 | 3.0 |
| No | 294 | 97.0 |
| Current pregnancy-related risk status | ||
| Yes | 7 | 2.3 |
| No | 296 | 97.7 |
| Pregnancy Status | ||
| Planned | 264 | 87.1 |
| Unplanned | 39 | 12.9 |
| Presence of Psychological Problems that require Continuous Assistance | ||
| Yes | 0 | 0 |
| No | 303 | 100.0 |
| Status of Anxiety Related to Childbirth | ||
| No anxiety | 64 | 21.1 |
| Slightly anxious | 201 | 66.3 |
| Very anxious | 38 | 12.5 |
| Previous Experience of a Major Disaster | ||
| Yes | 7 | 2.3 |
| No | 296 | 97.7 |
| Loss of a Relative as a Result of a Disaster | ||
| Yes | 2 | 0.7 |
| No | 301 | 99.3 |
| Availability of an Earthquake Emergency Kit at Home | ||
| Yes | 48 | 15.8 |
| No | 255 | 84.2 |
| Worrying about an earthquake in the city of residence | ||
| Yes | 215 | 71.0 |
| No | 88 | 29.0 |
Table 1 shows that the pregnant women who participated in the study had a mean age of 25 ± 3.247 years, 42.6% had their first pregnancy, 97.7% had not experienced a major disaster before, and 99.3% of the participants had not lost any relatives due to the disaster. The rate of pregnant women who did not have an earthquake emergency kit at home was 84.2%. It was also found that 71% of pregnant women were worried about an earthquake in their city.
Findings related to pregnant women’s perception of earthquake risk
Table 2 compares the earthquake risk perception of pregnant women according to their socio-demographic, obstetric and earthquake-related characteristics.
Table 2.
Comparison of earthquake risk perception of pregnant women according to their socio-demographic, obstetric and earthquake-related characteristics
| Variables | Cognitive Risk Perception | Affective Risk Perception | |||
|---|---|---|---|---|---|
| Range | Median | Range | Median | ||
| Number of Childbirths | 0 | 14.0 | 13.0b | 12.0 | 16.0b |
| 1 | 12.0 | 13.0b | 16.0 | 15.0ab | |
| 2 | 8.0 | 10.0a | 16.0 | 13.0a | |
| 3 | 13.0 | 11.0ab | 8.0 | 14.0ab | |
| p value | 0.000* | 0.004* | |||
| Current gestational week | <13 | 11.0 | 13.0 | 12.0 | 15.0ab |
| 13-27 | 13.0 | 12.0 | 12.0 | 16.0a | |
| ≥27 | 14.0 | 13.0 | 16.0 | 14.0b | |
| p value | 0.075 | 0.010* | |||
| Presence of adverse situation related to previous pregnancy | Yes | 8.0 | 14.0 | 7.0 | 14.0 |
| No | 14.0 | 13.0 | 16.0 | 15.0 | |
| p value | 0.005* | 0.994 | |||
| Current pregnancy-related risk status | Yes | 5.0 | 14.0 | 2.0 | 14.0 |
| No | 14.0 | 13.0 | 16.0 | 15.0 | |
| p value | 0.171 | 0.233 | |||
| Pregnancy status | Planned | 14.0 | 13.0 | 12.0 | 15.0 |
| Unplanned | 12.0 | 12.0 | 16.0 | 14.0 | |
| p value | 0.404 | 0.234 | |||
| Status of anxiety related to childbirth | No anxiety | 12.0 | 11.0a | 16.0 | 13.0a |
| Slightly anxious | 14.0 | 13.0b | 12.0 | 15.0b | |
| Very anxious | 11.0 | 13.0b | 9.0 | 16.0c | |
| p value | 0.000* | 0.000* | |||
| Previous experience of a major disaster | Yes | 3.0 | 19.0 | 5.0 | 19.0 |
| No | 14.0 | 13.0 | 16.0 | 15.0 | |
| p value | 0.000* | 0.004* | |||
| Loss of a relative as a result of a disaster | Yes | 3.0 | 18.5 | 0.0 | 15.0 |
| No | 14.0 | 13.0 | 16.0 | 15.0 | |
| p value | 0.023* | 0.023* | |||
| Availability of an earthquake emergency kit at home | Yes | 11.0 | 14.0 | 11.0 | 15.5 |
| No | 14.0 | 13.0 | 16.0 | 15.0 | |
| p value | 0.037* | 0.390 | |||
| Worrying about an earthquake in the city of residence | Yes | 12.0 | 13.0 | 16.0 | 16.0 |
| No | 13.0 | 10.0 | 12.0 | 12.0 | |
| p value | 0.000* | 0.000* | |||
| Age (Years) | r=-0.160, p=.005* | r=0.085, p=.140 | |||
| Age at First Pregnancy | r=-0.002, p=.968 | r=0.237, p=.001* | |||
a, b, c: Different superscript letters indicate statistically significant differences between groups
*p < 0.05
In Table 2, it was found that the cognitive risk perception sub-dimension median showed statistically significant differences in terms of age, adverse events related to previous pregnancies, loss of any relatives as a result of a disaster, and having an earthquake emergency kit at home (p < 0.05). However, affective risk perception sub-dimension median scores did not show statistically significant differences in terms of age, age at first pregnancy, adverse events related to previous pregnancies, loss of a relative as a result of a disaster, and having an earthquake emergency kit at home (p > 0.05) (Table 2). It was found that affective risk perception towards earthquake showed statistically significant differences in age at first pregnancy and in terms of the current gestational weeks of the pregnant women who participated in the study (p < 0.05).
Findings related to sleep problems of pregnant women
Table 3 shows the comparison of sleep problems of pregnant women according to their socio-demographic, obstetric and earthquake-related characteristics.
Table 3.
Comparison of Sleep Problems of Pregnant Women According to Socio-Demographic, Obstetric and Earthquake-Related Characteristics
| Variables | Problems due to physical symptoms | Problems due to changes in sleep-wake cycle | Problems due to deterioration in sleep quality | Problems due to respiratory system | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Range | Median | Range | Median | Range | Median | Range | Median | |||
| Number of childbirths | 0 | 29.0 | 28.0b | 23.0 | 19.0b | 11.0 | 15.0b | 8.0 | 6.0 | |
| 1 | 30.0 | 24.0a | 23.0 | 18.0ab | 16.0 | 13.0a | 7.0 | 5.0 | ||
| 2 | 26.0 | 25.0a | 20.0 | 15.5a | 11.0 | 13.0a | 7.0 | 5.0 | ||
| 3 | 21.0 | 20.0a | 12.0 | 18.0ab | 5.0 | 14.0ab | 10.0 | 5.0 | ||
| p value | 0.000* | 0.012* | 0.000* | 0.086 | ||||||
| Current gestational week | < 13 | 19.0 | 17.0a | 20.0 | 19.0b | 14.0 | 13.0a | 4.0 | 5.0a | |
| 13–27 | 25.0 | 24.0b | 19.0 | 18.0ab | 12.0 | 14.0b | 10.0 | 5.5b | ||
| ≥ 27 | 31.0 | 28.0c | 24.0 | 17.0a | 12.0 | 13.0a | 8.0 | 6.0b | ||
| p value | 0.000* | 0.032* | 0.002* | 0.001* | ||||||
| Adverse situation related to previous pregnancy | Yes | 23.0 | 35.0 | 14.0 | 17.0 | 5.0 | 15.0 | 8.0 | 6.0 | |
| No | 31.0 | 25.0 | 24.0 | 18.0 | 16.0 | 14.0 | 8.0 | 5.0 | ||
| p value | 0.002* | 0.944 | 0.148 | 0.134 | ||||||
| Current pregnancy-related risk status | Yes | 15.0 | 35.0 | 8.0 | 17.0 | 4.0 | 15.0 | 2.0 | 6.0 | |
| No | 31.0 | 25.0 | 24.0 | 18.0 | 16.0 | 14.0 | 10.0 | 5.0 | ||
| p value | 0.000* | 0.272 | 0.174 | 0.168 | ||||||
| Pregnancy status | Planned | 31.0 | 24.0 | 24.0 | 19.0 | 16.0 | 14.0 | 10.0 | 5.0 | |
| Unplanned | 27.0 | 28.0 | 18.0 | 17.0 | 12.0 | 14.0 | 8.0 | 6.0 | ||
| p value | 0.015* | 0.161 | 0.798 | 0.259 | ||||||
| Status of anxiety related to childbirth | No | 18.0 | 21.5a | 18.0 | 14.0a | 11.0 | 12.5a | 5.0 | 5.0a | |
| Slightly | 26.0 | 25.0b | 21.0 | 19.0b | 16.0 | 14.0a | 10.0 | 6.0b | ||
| Very | 26.0 | 31.5c | 19.0 | 22.5c | 11.0 | 17.0b | 7.0 | 6.0b | ||
| p value | 0.000* | 0.000* | 0.000* | 0.000* | ||||||
| Previous experience of a major disaster | Yes | 7.0 | 31.0 | 14.0 | 16.0 | 5.0 | 16.0 | 3.0 | 10.0 | |
| No | 31.0 | 25.0 | 24.0 | 18.0 | 16.0 | 14.0 | 10.0 | 5.0 | ||
| p value | 0.004* | 00.607 | 0.146 | 0.000* | ||||||
| Loss of a relative as a result of a disaster | Yes | 1.0 | 34.5 | 1.0 | 18.5 | 4.0 | 14.0 | 3.0 | 11.5 | |
| No | 31.0 | 25.0 | 24.0 | 18.0 | 16.0 | 14.0 | 8.0 | 5.0 | ||
| p value | 0.002* | 0.890 | 0.841 | 0.016* | ||||||
| Earthquake emergency kit at home | Yes | 18.0 | 25.5 | 22.0 | 17.0 | 12.0 | 14.0 | 8.0 | 5.0 | |
| No | 31.0 | 25.0 | 24.0 | 18.0 | 16.0 | 14.0 | 10.0 | 5.0 | ||
| p value | 0.272 | 0.398 | 0.597 | 0.450 | ||||||
| Worrying about an earthquake in the city of residence | Yes | 30.0 | 25.0 | 24.0 | 19.0 | 16.0 | 14.0 | 10.0 | 5.0 | |
| No | 31.0 | 25.0 | 19.0 | 17.0 | 12.0 | 13.0 | 7.0 | 5.0 | ||
| p value | 0.329 | 0.001* | 0.005* | 0.603 | ||||||
| Age (years) | r=-0.241, p=0.001* | r=-0.251, p= 0.001* | r=-0.236, p= 0.001* | r = 0.022, p= 0.706 | ||||||
| Age at first pregnancy | r=-0.064, p=0.269 | r=-0.161, p= 0.005* | r=-0.097, p=0.091 | r=-0.097, p=0.090 | ||||||
a, b, c: Different superscript letters indicate statistically significant differences between groups
*p < 0.05
When the scores of sleep problems due to physical symptoms during pregnancy sub-dimension of the SISPDP are examined in Table 3, statistically significant differences can be seen in terms of age, the number of childbirths, gestational week, adverse situation related to previous pregnancies, risk status related to the current pregnancy, intended pregnancy, anxiety related to childbirth, previous experience of a major disaster and loss of a relative as a result of a disaster (p < 0.05). It was found that the scores of sleep problems due to changes in the sleep-wake cycle sub-dimension showed statistically significant differences in terms of pregnant women’s age, age at first pregnancy, number of childbirths, current gestational week, anxiety related to childbirth, and worrying about an earthquake in the city where they lived (p < 0.05). It was found that the median of sleep problems due to deterioration in sleep quality during pregnancy sub-dimension showed statistically significant differences in terms of age, number of childbirths, gestational week, anxiety related to childbirth and worrying about an earthquake in the city where they lived (p < 0.05). Sleep problems related to respiratory system during pregnancy sub-dimension showed statistically significant differences in terms of gestational week, anxiety related to childbirth, previous experience of a major disaster and loss of a relative as a result of a disaster (p < 0.05). In the study, it was found that all sub-dimension median scores of SISPDP showed statistically significant differences in terms of the current gestational week of pregnant women and anxiety levels of pregnant women related to childbirth (p < 0.05).
The relationship between earthquake risk perception and sleep problems in pregnant women
The results of the correlation analysis between the total and sub-dimension and SISPDP total and sub-dimension values are shown in Tables 4 and 5.
Table 4.
The Relationship Between Earthquake Risk Perception in Pregnant Women and Sleep Problems During Pregnancy
| Earthquake Risk Perception Scale | Sleep Problems Scale for Pregnant Women | ||
|---|---|---|---|
| Earthquake Risk Perception Scale | r | 1.000 | 0.246 |
| p | . | 0.000* |
r: Spearman correlation analysis
*p < 0.05
Table 5.
The Relationship Between the Median Scores of the Earthquake Risk Perception Sub-Dimension of Pregnant Women and the Median Scores of the Sleep Problems During Pregnancy Sub-Dimension
| Affective Risk Perception | Sleep Problems Due to Physical Symptoms | Sleep Problems Due to Changes in Sleep-Wake Cycle | Sleep Problems Due to Deterioration in Sleep Quality | Sleep Problems Due to Respiratory System | ||
|---|---|---|---|---|---|---|
| Cognitive Risk Perception | r | 0.493 | 0.001 | 0.287 | 0.260 | 0.069 |
| p | 0.000 | 0.988 | 0.000* | 0.000* | 0.234 | |
| Affective Risk Perception | r | 0.174 | 0.155 | 0.025 | 0.220 | |
| p | 0.002* | 0.007* | 0.659 | 0.000* | ||
| Sleep Problems Due to Physical Symptoms | r | 0.245 | 0.334 | 0.393 | ||
| p | 0.000* | 0.000* | 0.000* | |||
| Sleep Problems Due to Changes in Sleep-Wake Cycle | r | 0.519 | 0.210 | |||
| p | 0.000* | 0.000* | ||||
| Sleep Problems Due to Deterioration in Sleep Quality | r | 0.277 | ||||
| p | 0.000* | |||||
r: Spearman correlation analysis
*p < 0.05
Table 4 shows that there is a significant relationship between earthquake risk perception and sleep problems experienced during pregnancy in the same direction (p<0.05). Table 5 shows that there are significant positive correlations between the sub-dimension of cognitive risk perception towards earthquake in pregnant women and sleep problems due to physical symptoms, changes in sleep-wake cycle and sleep problems related to respiratory system during pregnancy (p < 0.05). As the cognitive risk perception of earthquake increases in pregnant women, sleep problems due to physical symptoms, changes in sleep-wake cycle and respiratory system during pregnancy also increase (p=0.002, p=0.007, p=0.000, respectively) (Table 5). When the median scores of the sub-dimension of affective risk perception for earthquake in pregnant women were analysed, significant relationships were found between the sub-dimensions of sleep problems due to changes in sleep-wake cycle and sleep problems due to deterioration in sleep quality during pregnancy (p < 0.05). As the affective risk perception of pregnant women towards earthquake increased, sleep problems due to changes in sleep-wake cycle and deterioration in sleep quality during pregnancy also increased (p=0.000, p=0.000, respectively) (Table 5).
Discussion
In this study, socio-demographic, obstetric and earthquake-related characteristics of pregnant women, their earthquake risk perceptions and sleep problems were determined, and the relationships between earthquake risk perception and sleep problems were found.
Turkey has experienced devastating earthquakes in the past and scientists believe that there is a high probability of major earthquakes in the future https://www.mta.gov.tr/v3.0/bilgi-merkezi/deprem_potansiyeli. Experiencing an earthquake directly or indirectly can affect risk perception. Various studies show that women’s risk perception is higher than men’s and that women are more afraid of earthquakes [19, 31, 33, 34]. An increase in fear with the perception of risk can lead to sleep problems [35]. This situation made it necessary to investigate which factors affect the earthquake risk perception and sleep status of pregnant women who are in a special life period. It was found that 71% of the pregnant women who participated in the study were worried about an earthquake in the city where they lived (Table 1). In previous studies, it was reported that pregnant women who had experienced an earthquake experienced anxiety, depression and mental health problems, especially due to the fear of losing their loved ones [36]. In this study, it is thought that pregnant women were concerned about their health and the health of their loved ones, especially their babies. In the study, the socio-demographic characteristics and earthquake risk perception of pregnant women were evaluated in cognitive and affective dimensions. It was found that the number of childbirths, anxiety related to childbirth, previous experience of a major disaster, loss of a relative as a result of a disaster and worrying about an earthquake in the city where they lived affected both cognitive and affective risk perception of pregnant women (Table 2). In this context, these two risk perceptions need to be understood first. Cognitive perception allows the individual to evaluate, predict and understand the event [37]. Cognitive risk perception of earthquake reflects the perception that an earthquake is particularly likely to cause disaster, death, financial problems and danger to future generations [31]. Affective perception, on the other hand, describes individuals’ mental characteristics related to their feelings towards a situation or event [38]. Affective risk perception for earthquake reflects the perceptions of the earthquake on emotions such as fear, anxiety, terror and depression [31]. In the study, it was found that the risk perception of pregnant women who had never given birth and pregnant women who stated that they had high anxiety about childbirth was high in both cognitive and affective domains. Women may perceive the pregnancy process as uncertainty [39]. It is thought that this situation may cause an increase in the complexity of the process by adding the uncertainties brought by the perception of earthquake risk to the uncertainty experienced especially in primiparous women who have just experienced their first pregnancy. Pregnancy is a complex process that can be characterized by birth anxiety and can be affected by various factors that increase the risk perception of pregnancy [4, 18, 40]. One of these factors is environmental factors. As a matter of fact, environmental factors can create stress and anxiety in people. Individuals’ anxiety that they may experience loss and danger determines their perspective on risk perception [41]. Disasters cause temporary and permanent negative emotions in individuals. In post-disaster studies, it has been observed that individuals are more pessimistic about the future when they think about the disaster they have experienced [42, 43]. In the study, the median scores of both cognitive and affective risk perception towards earthquake were found to be high in pregnant women who stated that they had experienced a major disaster before, those who lost a relative as a result of the disaster and those who were worried about an earthquake in the city where they lived recently. This may be explained by the psychological distress, sleep and focusing problems frequently seen after an earthquake, as well as the constant visualization of the earthquake in the mind [38, 44]. Findings revealed that cognitive risk perception decreased in relation to maternal age, while affective risk perception increased alongside age at first pregnancy. These divergent relationships suggest that maternal age and reproductive history are associated with different cognitive and emotional responses to earthquake risks. In Bayrampour’s (2013) study, similar to this study, the risk perception levels of pregnant women in the higher age group were found to be higher. Some other studies have also reported that one of the factors associated with risk perception in older women is gestational age [17, 45]. Higher affective risk scores in women with advanced age at first pregnancy may reflect an intensified protective instinct. This relationship suggests that older first-time mothers might be more sensitive to perceived environmental risks to ensure their infant’s safety. Therefore, increasing age is a factor that increases risk perception in women [31]. The fact that cognitive risk perception reflects the perception of danger for future generations explains this situation. Similarly, it is thought that the high cognitive risk perception of pregnant women who experienced a negative situation with the previous pregnancy is also related to this situation. Affective risk perception of pregnant women was found to be higher in the second trimester. The study conducted by Gözüyeşil and Özertürk (2022) supports these results [46]. In the aforementioned study, it was found that both the total score and maternal and infant risk perception of pregnant women in the second trimester were higher than the others and the difference was statistically significant. In the second trimester, pregnant women’s instinct to protect their babies increases more [47]. This period, when women begin to feel their baby’s movements, is characterized by narcissism and introversion. The clothes they wear, the food they consume, and especially the impact of environmental events on the fetus’s health become more important to pregnant women [47]. Pregnancy-related conditions, particularly in the second trimester, influence earthquake risk perception. This is likely due to the emotional bond pregnant women form with their babies through fetal movements [48] and that they perceive earthquake as a risk due to the concern of survival in the external environment if the baby is born in this process.
In this study, the socio-demographic characteristics and sleep problems of pregnant women were evaluated with the sub-dimensions of physical symptoms, change in sleep-wake cycle, deterioration in sleep quality and sleep problems related to respiratory system (Table 3). The study found that gestational week and childbirth anxiety caused sleep problems. In the third trimester (27 + weeks), physical and respiratory symptoms were more common, while in the second trimester (13–27 weeks), sleep quality declined, and in the first trimester (< 13 weeks), sleep-wake cycle changes occurred, likely due to nausea and vomiting [49]. The median scores of all sub-dimensions of the SISPDP were highest in pregnant women who stated that they were very anxious about childbirth. In other words, anxiety about childbirth increases sleep problems. Similarly, Uçar et al. (2022) reported that severe fear of childbirth was associated with sleep disturbance in their study [50]. In this study the inverse relationship observed between maternal age and sleep-related problems is noteworthy. This association may reflect a higher level of physiological adaptation or a more established lifestyle routine in older pregnant women, which could be linked to better management of sleep-wake cycles.
In the analyses conducted a low, positive and significant relationship was found between earthquake risk perception and sleep problems in pregnant women (Table 4). In other words, as the perception of earthquake risk increases in pregnant women, sleep problems also increase. In the literature, there are various studies on sleep problems or earthquake in pregnant women [51]. However, no studies were found examining the relationship between earthquake risk perception and sleep problems. Individuals’ anxiety that they may experience loss and danger determines their perspective on risk perception [41]. Disasters create lasting negative emotions; a study showed individuals became more pessimistic about the future after experiencing one [42, 43, 52]. Studies have found that earthquakes, which are among the most stressful events, can directly affect the mental health of peripartum women [53, 54]. In a study on earthquake, it was reported that the negative effects of the earthquake disappeared after four years [51]. Studies show that prolonged exposure to earthquake-related risk factors harms pregnant women’s psychological well-being, perinatal health, and sleep quality [55, 56]. A study found a significant link between perceived stress and sleep quality in pregnant women [57]. It is thought that the perception of earthquake risk during pregnancy causes pregnant women to experience stress at a high level, negatively affects their circadian rhythm and causes sleep disorders. In this context, it is important for all health professionals, especially nurses, to evaluate the earthquake risk perception and the effect of this perception on sleep, especially in pregnant women who have recently experienced earthquakes directly or indirectly.
The study found a low, positive and significant relationship between cognitive and affective risk perception towards earthquake and sleep problems due to changes in the sleep-wake cycle (Table 5). Worries experienced during pregnancy negatively affect circadian rhythm and sleep through hormones [58–61]. Changes in cortisol hormone levels affect the sleep-wake cycle [62]. While the production of cortisol is at its lowest level at midnight, it increases in situations such as stress, fear and anxiety. The high level of cortisol hormone during the day also disrupts the circadian rhythm and increases sleep disorders [63]. In this context, it is thought that the fear and anxiety caused by earthquake risk perception on pregnant women increase the level of cortisol hormone and cause sleep problems due to changes in sleep-wake cycle.
Conclusion and recommendations
The study found a significant relationship between the earthquake risk perception of pregnant women and sleep problems. Women, who constitute the disadvantaged segment of the society in environmental disasters, eagerly await the realization of the act of “being born” in a period such as pregnancy. On the other hand, experiencing or the possibility of experiencing a natural disaster such as an earthquake, which is frequently mentioned in the concept of “death”, in this period may bring about negative consequences related to pregnancy. The literature often highlights these results, but the key question is whether pregnant women manage environmental events like earthquakes through accurate risk perception or create harm due to inaccurate perceptions. This study found that pregnant women had high earthquake risk perception and sleep problems, with a correlation between the two. These findings suggest that studying pregnant women more sensitive to earthquakes could enhance understanding of factors influencing their risk perception. Developing effective disaster management training for pregnant women in high-risk earthquake areas is crucial. Health professionals can support positive risk perception by raising awareness and providing guidance.
Acknowledgements
Not applicable.
Authors’ contributions
AM served as the primary investigator, responsible for data collection, instrument preparation, statistical analysis, and the initial draft of the manuscript. TMA and FA was accountable for ensuring the correct methodology, preparation, and finalization of the psychological tools used in the study. Additionally, he served as the lead consultant for the research and significantly contributed to the manuscript preparation. TP led the study, developed the study’s concept, coordinated all assignments, and significantly contributed to the manuscript preparation. All authors read and approved the final manuscript.
Funding
There is no funding for the study.
Data availability
The data included in this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Approval was obtained from Erzurum Technical University Scientific Research and Publication Ethics Committee before starting the study (06/06/25.05.2023). For the scales used in the study, permission was obtained from the researchers who adapted/developed the scales. In addition, institutional permission was obtained from Tokat Provincial Health Directorate (24.08.2023 dated E-87064461-044-222965811). Pregnant women who met the inclusion criteria and agreed to participate in the study were informed about the study and their verbal and written consents were obtained. All stages of the study were conducted in accordance with the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
This study was submitted as an oral presentation to the International Symposium on Intercultural Nursing in Disasters (8–9 November 2024).
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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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
The data included in this study are available from the corresponding author upon reasonable request.