Abstract
Background
Pregnancy-related anxiety can adversely affect maternal and fetal health; therefore, understanding its related factors is essential. This study aimed to determine the cognitive-psychological predictors of pregnancy-related anxiety among pregnant women.
Methods
This cross-sectional study was conducted on 400 pregnant women who were covered by urban comprehensive health service centers in Urmia. Data were collected using a demographic questionnaire; the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R2); the Edinburgh Postnatal Depression Scale (EPDS); the Multidimensional Scale of Perceived Social Support (MSPSS); the Childbirth Self-Efficacy Inventory (CBSEI); and the Maternal Health Literacy and Pregnancy Outcome Questionnaire (MHLAPQ). The data were analyzed using SPSS version 16. A p-value of less than 0.05 was considered statistically significant.
Results
The mean age of participants was 26.53 ± 4.87 years. The mean pregnancy-related anxiety score was 28.03 ± 9.08. Among the subscales of pregnancy-related anxiety, the lowest mean score was associated with concerns about own appearance, while the highest mean score was linked to fear of childbirth. Depression during pregnancy (B = 0.821, β = 0.523, p < 0.001) and childbirth self-efficacy (B = − 0.048, β = −0.176, p < 0.001) were significant predictors of pregnancy-related anxiety, whereas perceived social support and maternal health literacy were not significant predictors. The cognitive-psychological variables examined explained approximately 34% of the variance in pregnancy-related anxiety.
Conclusions
The results showed a moderate level of pregnancy-related anxiety in the study population. Therefore, it is recommended to incorporate early screening for pregnancy-related anxiety and its related factors into routine care. Furthermore, appropriate interventions should be implemented to reduce pregnancy-related anxiety by addressing its predictors.
Keywords: Cognitive variables, Psychological variables, Pregnancy-Related Anxiety, Pregnant Women
Introduction
Pregnancy-related anxiety is a distressing psychological condition characterized by concerns about both the current and future aspects of pregnancy. These worries often include fears surrounding childbirth, the baby’s health, and the transition to motherhood. It is important to distinguish this condition from generalized anxiety, which represents a broader state of chronic unease and worry [1]. The prevalence of pregnancy-related anxiety in developing countries ranges from 10% to 25%. In Iran, studies utilizing the General Anxiety Questionnaire have indicated a significant prevalence of this condition, with reported rates of 32.5% and 40% [2].
Anxiety is a natural response to stressful situations. Consequently, lower levels of pregnancy-related anxiety can positively influence a woman’s adherence to health-related recommendations. Conversely, excessive anxiety can adversely affect both the physical and mental health of women, as well as the cognitive, emotional, and behavioral development of their offspring. Numerous studies have consistently demonstrated a correlation between pregnancy-related anxiety and a range of health-related complications, including intrauterine growth restriction, preterm birth, cleft lip and palate, stillbirth, infant mortality, autism, hyperactivity, and neurodevelopmental impairments [1–3].
Given the significant implications of pregnancy-related anxiety for both maternal and fetal well-being, it is essential to understand the factors that contribute to its emergence and persistence. Furthermore, effective management and prevention of this condition require a comprehensive exploration of its associated factors.
A pivotal factor influencing pregnancy-related anxiety is the presence of maternal depression during gestation, a relationship supported by existing research [4]. Depressive disorder is a clinical condition characterized by a period of at least two weeks of low mood or anhedonia, accompanied by at least five of the following symptoms: changes in appetite or weight; sleep disturbances; psychomotor symptoms such as restlessness or retardation; diminished energy; feelings of worthlessness or guilt; hopelessness or helplessness; difficulty concentrating or making decisions; and recurrent thoughts of death or suicide [5]. Depression in early pregnancy predicts higher levels of anxiety in late pregnancy, while anxiety in late pregnancy predicts higher levels of depression in the early postpartum period [6].
Another factor influencing pregnancy-related anxiety is the level of health literacy among pregnant women. Lower levels of health literacy are correlated with increased pregnancy-related anxiety [7]. Health literacy encompasses a multifaceted set of skills, including reading, listening, analysis, decision-making, and the ability to apply these competencies in health-related contexts. Importantly, health literacy is not solely dependent on formal education or general reading ability [8].
Another influential factor in pregnancy-related anxiety is perceived social support [4, 9]. Perceived social support refers to an individual’s subjective belief or appraisal that they will receive adequate assistance from their social network when needed. This perceived support can enhance confidence in solving various problems more effectively. According to psychological stress theory, social support plays a pivotal role in mitigating the harmful effects of stress and promoting overall well-being, both physically and psychologically [9].
The next variable worthy of exploration in the context of pregnancy-related anxiety is the concept of childbirth self-efficacy. Pregnant women who experience anxiety often demonstrate a reduced level of childbirth self-efficacy. Childbirth self-efficacy refers to a mother’s belief in her ability to have a natural childbirth with minimal intervention, as well as her capacity to manage the pain associated with childbirth and maintain control in the face of maternal, fetal, or neonatal complications [10]. Wernand and colleagues investigated the relationship between self-efficacy, depression, and anxiety. They found that greater psychopathology was linked to lower self-efficacy across all trimesters of gestation [11].
Regarding the mechanism through which cognitive and psychological variables—including depression, health literacy, social support, and perceived self-efficacy—influence pregnancy-related anxiety, it should be explained that these variables can play a role in the onset and maintenance of pregnancy-related anxiety through their effects on cognitive appraisals and biases, as well as through their influence on emotion regulation strategies. Evidence indicates that depression is associated with deficits in the use of adaptive emotion regulation strategies [12]; higher health literacy is associated with reduced cognitive biases [13]; greater perceived social support is associated with increased use of adaptive emotion regulation strategies and more positive cognitive appraisals [14]; and individuals with higher levels of self-efficacy typically demonstrate more successful emotion regulation techniques [15].
Cognitive processing biases refer to mental errors and distorted patterns in the way information is attended to, interpreted, and remembered. In the context of anxiety, these biases act as a mechanism through which ambiguous or neutral stimuli are selectively processed as threatening, thereby contributing to the development and maintenance of anxiety symptoms. For example, anxious individuals tend to remember threatening events more frequently, and this recall perpetuates and intensifies anxiety. During pregnancy, cognitive biases in the domains of attention, interpretation, and memory are key factors in the initiation and maintenance of pregnancy-related anxiety [16, 17].
Emotion regulation involves the use of behavioral and cognitive strategies to modify the duration or intensity of an emotional experience. Theoretically, any deficit in emotion regulation can render an individual vulnerable to mental disorders such as anxiety. Individuals who exhibit cognitive biases are typically unable to manage their emotional responses to stressful events in an adaptive manner [17].
Given the importance of identifying factors associated with pregnancy-related anxiety, this study aims to determine the cognitive-psychological predictors of this condition among pregnant women. A comprehensive literature review revealed that it appears no study—globally, in Iran, or specifically in Urmia City—has simultaneously examined the combined effects of depression, health literacy, social support, and childbirth self-efficacy on pregnancy-related anxiety. Accordingly, the findings of this study can enhance the understanding of researchers and healthcare policymakers, both in Iran and internationally, regarding the predictors of pregnancy-related anxiety. This improved understanding may facilitate the management of these variables and help reduce pregnancy-related anxiety through the design and implementation of targeted psychological interventions.
Methods
This descriptive-analytical, cross-sectional study was conducted in 2023. The study population consisted of all pregnant women who were covered by urban comprehensive health service centers in Urmia, Iran. Inclusion criteria were as follows: (a) being married; (b) age between 18 and 35 years; (c) gestational age between 12 and 28 weeks; (d) ability to read and write; (e) providing informed consent; and (f) having the physical and mental capacity to answer the questionnaires. Exclusion criteria included a history of mood disorders as well as a high-risk pregnancy (i.e., cardiovascular, pulmonary, or thyroid conditions). Incomplete questionnaires were excluded from the final analysis.
The minimum required sample size was calculated as 373 individuals based on the correlation coefficient between pregnancy-related anxiety and perceived social support (r = − 0.198) [18], a 99% confidence level, and 90% statistical power, using the sample size formula for correlation studies. To enhance the study’s power and account for potential attrition, a total of 400 participants were ultimately included.
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Sampling was conducted using a multi-stage cluster sampling method. First, Urmia City was divided into four geographic regions: north, south, east, and west. From each region, one urban comprehensive health service center was randomly selected using a lottery method. Next, in consultation with the heads of the selected centers, a list of pregnant women who met the inclusion criteria was compiled. Then, using simple random sampling (also via lottery), 100 pregnant women were selected from each center. Potential participants were contacted by phone, and the study objectives were explained to them. Those who consented to participate were asked to provide the date of their first routine health center visit. On that date, interviewers attended the center to complete the questionnaire.
The data collection instruments for this study were organized into six distinct sections. The first section covered the demographic characteristics of the participants, including age, gestational age, educational level, employment status, husband’s educational level and employment status, ethnicity, residential status, and economic status [19].
The second section of the data collection instruments is the Maternal Health Literacy and Pregnancy Outcome Questionnaire (MHLAPQ). The health literacy section of this questionnaire was used to assess maternal health literacy. The Persian version of this section consists of 14 items; each rated on a four-point Likert scale ranging from “strongly agree” to “strongly disagree.” Total scores range from 14 to 56, with higher scores indicating greater maternal health literacy. The validity and reliability of the Persian version of the MHLAPQ were examined by Kharazi et al., who confirmed the validity of the questionnaire for both the maternal health literacy and pregnancy outcome sections through face validity (quantitative), qualitative and quantitative content validity (CVR and CVI), and construct validity (exploratory and confirmatory factor analysis with appropriate fit indices). Reliability was also confirmed, with a Cronbach’s alpha coefficient of 0.89 for the maternal health literacy section and 0.67 for the pregnancy outcome section [20].
The third section of the data collection instruments is the Edinburgh Postnatal Depression Scale (EPDS), a widely used tool for screening risk of depressive symptoms during pregnancy and the postpartum period. The EPDS was developed by Cox et al. in 1987 and revised in 1994 [21]. It consists of ten items, each with four response options scored on a Likert scale. Some items are scored from low to high intensity (items 1, 2, and 4), while others are reverse-scored from high to low intensity (items 3, 5, 6, 7, 8, 9, and 10). Each item yields a score of 0 to 3, with total scores ranging from 0 to 30. Participants are asked to select responses that reflect their emotional state over the past week. A cut-off point of 12 has been established, with reported sensitivity of 78% and specificity of 75% [22]. Therefore, a total score of 12 or higher indicates a positive screen for depressive symptoms.
In the study by Montazeri et al., the validity and reliability of the Persian version of the EPDS were confirmed. Cronbach’s alpha coefficients were 0.77 and 0.86 at two time points, respectively, and the intraclass correlation coefficient (ICC) was 0.80, indicating good reliability. The questionnaire was able to distinguish between women with normal vaginal delivery and cesarean section (known-groups validity), and its negative correlation with the mental health component of the SF-36 showed acceptable convergent validity. Furthermore, exploratory factor analysis revealed a three-factor structure that explained 58% of the total variance [23].
The fourth section is the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R2). This instrument was initially developed in 1999 by Van den Bergh to assess pregnancy-related fears and concerns, and originally consisted of 34 items across 5 subscales. Later, using a factor analytic approach, Huizink et al. identified subscales with high factor loadings and consolidated the original 5 subscales into 3: fear of childbirth (3 items), worries about bearing a handicapped child (4 items), and concerns about one’s own appearance (3 items). Consequently, they reduced the total number of items from 34 to 10. The PRAQ-R2 employs a 5-point Likert scale, with each item scored from 1 to 5. Thus, total scores range from 10 to 50, with higher scores indicating greater levels of pregnancy-related anxiety [24].
In the study by Bayrampour et al., the validity and reliability of the Persian version of the PRAQ-R2 were examined and confirmed. Content validity was evaluated using two methods: qualitative (expert opinion) and quantitative (CVR and CVI), yielding a content validity ratio (CVR) of 0.98 and a content validity index (CVI) of 0.97. The reliability of the questionnaire was reported with a Cronbach’s alpha of 0.74 for the total instrument. Additionally, the intraclass correlation coefficient (ICC) was calculated as 0.73, indicating appropriate stability of the results over time. Furthermore, confirmatory factor analysis confirmed the three-factor structure of the questionnaire [25].
The fifth section is the Multidimensional Scale of Perceived Social Support (MSPSS). This instrument was developed by Zimet et al. in 1988 to assess perceived social support from family, friends, and significant others. The MSPSS consists of 12 items, each rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores range from 12 to 60, with higher scores indicating greater perceived support from family, friends, and significant others. In the study by Bagherian-Sararoudi et al., the validity and reliability of the Persian version of the MSPSS were examined and confirmed. For construct validity, exploratory factor analysis was used, which confirmed the three-factor structure with explained variances of 77.87% in the patient group and 78.55% in the healthy group. The reliability of the questionnaire, calculated using Cronbach’s alpha for the total instrument, was 0.83 in the patient group and 0.92 in the healthy group. Additionally, the intraclass correlation coefficient (test-retest with a two-month interval) in the healthy group was 0.84 for the total questionnaire, indicating appropriate stability of results over time [26].
The sixth section is the Childbirth Self-Efficacy Inventory (CBSEI), originally developed by Lowe (1993) to assess a mother’s confidence in facing childbirth [18]. This questionnaire consists of 17 items, each scored on a scale from 1 to 10, resulting in total scores ranging from 17 to 170. A higher score indicates greater childbirth self-efficacy [27]. In the study by Khorsandi et al., the validity and reliability of the Iranian short form of the Childbirth Self-Efficacy Inventory were confirmed. Content validity was established by an expert panel. Construct validity supported the two-factor structure (Outcome Expectancy and Efficacy Expectancy) with good fit indices. Convergent validity was confirmed by a significant correlation between subscales, and divergent validity was established by known-groups analysis (primiparous vs. multiparous). Reliability was also acceptable, with a Cronbach’s alpha of 0.92 and a split-half coefficient of 0.78 [28].
In the present study, Cronbach’s alpha coefficients were evaluated as 0.953 for childbirth self-efficacy, 0.932 for health literacy, 0.911 for perceived social support, 0.906 for pregnancy-related anxiety, and 0.802 for depression. These values indicate desirable and acceptable internal consistency for all questionnaires in the studied population.
To facilitate comparison across different instruments, all scale scores were transformed to a percentage scale (out of 100). This transformation was calculated using the formula: (raw score × 100) / maximum possible scale score. For example, the PRAQ-R2 scores (maximum possible scale score: 50 and raw score: 28.03) were transformed using the formula: (28.03 × 100) / 50. Thus, the mean score (out of 100) of pregnancy-related anxiety was 56.06, as reported in Table 2.
Table 2.
Mean and standard deviation of cognitive-psychological variables under investigation (n = 398)
| Variables | Mean ± SD | Scale rangea | Min-Maxb | Mean score (Out of 100) |
|
|---|---|---|---|---|---|
| Pregnancy-related anxiety | Fear of Childbirth | 10.11 ± 2.85 | 3–15 | 3–15 | 67.42 ± 19.00 |
| Worries about bearing a handicapped child | 11.15 ± 4.49 | 4–20 | 4–20 | 55.77 ± 22.49 | |
| Concerns about own appearance | 6.76 ± 3.50 | 3–15 | 3–15 | 45.07 ± 23.39 | |
| Total | 28.03 ± 9.08 | 10–50 | 10–50 | 56.06 ± 18.17 | |
| Perceived social Support | Family | 15.38 ± 3.67 | 4–20 | 4–20 | 76.92 ± 18.39 |
| Friends | 9.38 ± 5.55 | 4–20 | 4–20 | 46.93 ± 27.79 | |
| Significant others | 14.62 ± 3.87 | 4–20 | 4–20 | 73.12 ± 19.39 | |
| Total | 39.39 ± 10.76 | 12–60 | 12–60 | 65.66 ± 17.94 | |
| Maternal health literacy | 50.73 ± 7.06 | 14–56 | 22–56 | 90.60 ± 12.62 | |
| Childbirth self-efficacy | 104.85 ± 33.18 | 17–170 | 25–170 | 61.67 ± 19.52 | |
| Depression during pregnancy | 5.88 ± 5.79 | 0–30 | 0–21 | 19.63 ± 19.31 | |
Abbreviation: SD standard deviation
a the lowest and highest values that can be obtained from the original scale
b the lowest and highest values obtained in this study
The ethical considerations of the present study included obtaining ethical approval from the Research Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1401.292). Additionally, a written introduction letter from the Vice-Chancellor for Research and Technology at Urmia University of Medical Sciences was provided to the research settings. The researcher was present in these settings to explain the study’s objectives and methods. Informed consent was obtained from all participants, who were assured that their participation was voluntary and that they could withdraw at any time. Participants were also informed that their information would remain confidential and that study results would only be reported in aggregate. To further protect privacy, the questionnaires did not include personal identifiers such as names or surnames.
Data analysis was performed using SPSS version 16. Descriptive statistics, including mean, standard deviation, frequency, percentage, minimum, and maximum, were used to provide a comprehensive overview of the data. The Kolmogorov-Smirnov test was used to assess data normality. Furthermore, Pearson correlation and multiple linear regression (using the Enter method) were conducted to explore relationships between variables. A p-value of less than 0.05 was considered statistically significant.
Results
A total of 400 questionnaires were distributed, of which 2 were excluded from analysis due to incomplete data. Consequently, data from 398 pregnant women were analyzed, yielding a response rate of 99.5%. The mean age of participants was 26.53 ± 4.87 years, and the mean gestational age was 21.55 ± 5.16 weeks. The majority held a high school diploma (56.5%) and were housewives (82.2%), with 50.3% reporting medium economic status. Additional demographic characteristics are presented in Table 1.
Table 1.
Demographic characteristics of pregnant women in the study (n = 398)
| Variable | Category | Frequency (Percentage) |
|---|---|---|
| Employment status | Housewife | 327 (82.2) |
| Government employee | 23 (5.8) | |
| Self-employed | 16 (4.0) | |
| Student | 32 (8.0) | |
| Educational level | Elementary | 27 (6.8) |
| Middle school | 46 (11.6) | |
| High school diploma | 225 (56.5) | |
| Associate degree | 18 (4.5) | |
| Bachelor degree | 67 (16.8) | |
| Master degree | 15 (3.8) | |
| Husband’s employment status | Unemployed | 8 (2.0) |
| Government employee | 107 (26.9) | |
| Self-employed | 221 (55.5) | |
| Student | 15 (3.8) | |
| Worker | 47 (11.8) | |
| Husband’s educational level | Elementary | 24 (6.0) |
| Middle school | 45 (11.3) | |
| High school diploma | 158 (39.7) | |
| Associate degree | 36 (9.0) | |
| Bachelor degree | 65 (16.4) | |
| Master degree | 54 (13.6) | |
| Doctorate | 16 (4.0) | |
| Ethnic affiliation | Turk | 265 (66.6) |
| Kurd | 129 (32.4) | |
| Fars | 4 (1.0) | |
| Residential status | Owner | 170 (42.7) |
| Rental | 228 (57.3) | |
| Economic status | Weak | 101 (25.3) |
| Medium | 200 (50.3) | |
| Good | 85 (21.4) | |
| Excellent | 12 (3.0) | |
| Age (years) | Mean | SD |
| 26.53 | 4.87 | |
| Gestational age (weeks) | 21.55 | 5.16 |
Abbreviation: SD standard deviation
The mean scores of the cognitive-psychological variables are presented in Table 2. Participants reported a mean pregnancy-related anxiety score of 28.03 ± 9.08. Among the subscales of pregnancy-related anxiety, the lowest mean score was related to concerns about one’s own appearance (45.07 out of 100), while the highest mean score was related to fear of childbirth (67.42 out of 100). Regarding perceived social support, participants reported the lowest levels of support from friends (46.93 out of 100) and the highest levels of support from family (76.92 out of 100). The participants achieved a maternal health literacy score of 90.60 out of 100, a childbirth self-efficacy score of 61.67 out of 100, and a pregnancy depression score of 19.63 out of 100. Of the pregnant women participating in the study, 89 (22.40%) screened positive for depressive symptoms.
Pearson correlation coefficients between the cognitive-psychological variables under investigation and pregnancy-related anxiety are presented in Table 3. The results showed a significant inverse correlation between maternal health literacy and pregnancy-related anxiety (r = − 0.188, p < 0.001), as well as between childbirth self-efficacy and pregnancy-related anxiety (r = − 0.244, p < 0.001). A significant positive correlation was observed between depression during pregnancy and pregnancy-related anxiety (r = 0.557, p < 0.001). However, no statistically significant correlation was found between perceived social support and pregnancy-related anxiety (r = − 0.094, p = 0.061).
Table 3.
Correlation Coefficients Between Cognitive-Psychological Variables and Pregnancy-Related Anxiety
| Variable | r | p |
|---|---|---|
| Perceived social support | -0.094 | 0.061 |
| Maternal health literacy | −0.188 | < 0.001 |
| Childbirth self-efficacy | −0.244 | < 0.001 |
| Depression during pregnancy | 0.557 | < 0.001 |
The results of the regression coefficients for predictors of pregnancy-related anxiety, based on the cognitive-psychological variables under investigation, are presented in Table 4. According to the findings, depression during pregnancy (B = 0.821, β = 0.523, p < 0.001) and childbirth self-efficacy (B = − 0.048, β = −0.176, p < 0.001), respectively, had the largest impact and were significant predictors of pregnancy-related anxiety. This indicates that for every one-unit increase in the depression score, the pregnancy-related anxiety score increased by 0.821 units. Conversely, for every one-unit increase in the childbirth self-efficacy score, the pregnancy-related anxiety score decreased by 0.048 units. Collectively, the cognitive-psychological variables examined explained approximately 34% of the variance in pregnancy-related anxiety.
Table 4.
Regression Coefficients of Predictors of Pregnancy-Related Anxiety Based on Cognitive-Psychological Variables Under Investigation
| Variable | Unstandardized coefficients | Standardized coefficients | t | p | R2 | |
|---|---|---|---|---|---|---|
| B | SE | β | ||||
| Constant | 31.042 | 3.604 | - | 8.613 | < 0.001 | 0.343 |
| Perceived social Support | -0.027 | 0.035 | -0.032 | -0.765 | 0.445 | |
| Maternal health literacy | -0.034 | 0.057 | -0.026 | -0.596 | 0.551 | |
| Childbirth self-efficacy | -0.048 | 0.012 | -0.176 | -4.194 | < 0.001 | |
| Depression during pregnancy | 0.821 | 0.069 | 0.523 | 11.855 | < 0.001 | |
Abbreviations: SE, Standard error; R2, R-squared
Consistent with the earlier analysis, the adjusted regression results confirmed that depression during pregnancy (B = 0.820, β = 0.523, p < 0.001) and childbirth self-efficacy (B = − 0.049, β = −0.180, p < 0.001) remained significant predictors of pregnancy-related anxiety, with depression exhibiting the strongest effect. The cognitive-psychological variables examined in this study explained approximately 35% of the variance in pregnancy-related anxiety after adjusting for demographic variables (Table 5).
Table 5.
Regression Coefficients* of Predictors of Pregnancy-Related Anxiety Based on Cognitive-Psychological Variables Under Investigation
| Variable | Unstandardized coefficients | Standardized coefficients | t | p | R2 | |
|---|---|---|---|---|---|---|
| B | SE | β | ||||
| Constant | 27.922 | 4.404 | - | 6.340 | < 0.001 | 0.351 |
| Perceived social Support | -0.027 | 0.037 | -0.032 | -0.729 | 0.466 | |
| Maternal health literacy | -0.073 | 0.069 | -0.057 | -1.059 | 0.290 | |
| Childbirth self-efficacy | -0.049 | 0.012 | -0.180 | -4.117 | < 0.001 | |
| Depression during pregnancy | 0.820 | 0.072 | 0.523 | 11.340 | < 0.001 | |
*Adjusted for age, gestational age, education level, employment status, ethnic affiliation, and economic status
Abbreviations: SE, Standard error; R2, R-squared
Discussion
Based on the findings of the present study, the mean pregnancy-related anxiety score among pregnant women covered by urban comprehensive health service centers in Urmia was 28.03 ± 9.08. According to the classification by Srinivasan et al. [29], which defines scores of 21–30 as moderate anxiety based on the PRAQ-R2, this indicates a moderate level of anxiety. In studies conducted in Iran by Ghanbari-Homaie et al. [30] and Rafiei et al. [18], the mean pregnancy-related anxiety scores were reported as 22.4 ± 9.28 and 24.00 ± 6.80, respectively. According to the classification of pregnancy-related anxiety levels [29], these scores are considered moderate. However, the mean pregnancy-related anxiety scores in both studies [18, 30] were lower than the mean anxiety observed in the current study.
Consistent with the findings of the present study, research conducted by Al Ghadeer et al. in Saudi Arabia revealed that the mean pregnancy-related anxiety score among women visiting healthcare centers was 28 out of 50, indicating a moderate level of anxiety [31]. Similarly, a study by Langille et al. in Canada reported a mean pregnancy-related anxiety score of 27.3 ± 6.7, also reflecting a moderate level of anxiety [32].
Given the significant impact of pregnancy-related anxiety on both maternal and fetal well-being, the current situation is unacceptable. Therefore, in addition to routine prenatal care, it is essential to design and implement targeted psychological interventions aimed at reducing pregnancy-related anxiety among pregnant women in Urmia City. To enhance the effectiveness of these interventions, they should be designed and implemented with a greater emphasis on the dimensions of pregnancy anxiety in which the women studied have reported higher scores and greater concern, as well as on the variables that were identified as significant predictors of pregnancy-related anxiety.
Based on the findings of the current study, the highest mean score was associated with fear of childbirth. In other words, participants expressed greater concern about the pain associated with contractions and delivery, the overall childbirth process, and the fear of losing control during labor and screaming. Conversely, the lowest mean score was related to concerns about one’s own appearance.
Consistent with the present study, Rafiei et al. [18] reported that the fear of childbirth was the most significant concern among pregnant women, while worries about bearing a handicapped child and concerns about own appearance were the least prevalent sources of pregnancy-related anxiety. Similarly, Naja et al. [33] found that the greatest concern among pregnant women in Qatar was related to childbirth, with the least concern regarding their own appearance. Likewise, Al Ghadeer et al. [31] in Saudi Arabia reported that the highest mean score was associated with the fear of childbirth. This consistency across different populations and cultural contexts suggests that fear of childbirth is a universal and dominant concern among pregnant women, highlighting the need for targeted interventions to address this specific aspect of pregnancy-related anxiety.
The finding that fear of childbirth was the subscale of pregnancy-related anxiety with the highest mean score can be explained by the fact that childbirth is a unique event that is accompanied by two key psychological processes: intolerance of uncertainty and pain catastrophizing. Intolerance of uncertainty refers to the tendency to worry about unpredictable and uncertain events—such as childbirth—and their potentially negative consequences. Pain catastrophizing is defined as the tendency to exaggerate the anticipation of pain and its outcomes. These two processes are related yet conceptually distinct, and both appear to be important for understanding fear of childbirth [34].
As previously noted, another crucial consideration in the design and implementation of anxiety-reduction interventions for pregnant women is the integration of predictors of pregnancy-related anxiety into these interventions. The current study identified depression during pregnancy as the strongest predictor of pregnancy-related anxiety; as depression levels increased, anxiety also increased. In line with this finding, studies by Tarafa et al. in Ethiopia [4] and Nath et al. in India [35] reported a positive and significant relationship between depression and pregnancy-related anxiety. Although the coexistence of anxiety and depression in pregnant women is well-documented, the underlying mechanisms and temporal sequence of these conditions remain unclear [4, 35]. Consequently, it is recommended to integrate depression-reduction interventions into all programs designed to alleviate pregnancy-related anxiety. Such interventions may include spiritual counseling [36], increased physical activity [37], deep breathing exercises, mindfulness techniques, and muscle relaxation strategies [38].
Childbirth self-efficacy was another predictor of pregnancy-related anxiety among pregnant women covered by urban comprehensive health service centers in Urmia. As childbirth self-efficacy increased, pregnancy-related anxiety decreased. This finding may be explained by the fact that women with low childbirth self-efficacy have a limited capacity to tolerate childbirth pain and perceive themselves as less capable of managing the labor process, which can exacerbate feelings of fear and anxiety [10]. In line with this finding, Nikbakht et al. identified a significant negative correlation between childbirth self-efficacy and pregnancy-related anxiety. Their study revealed that a pregnant mother’s anxiety mainly stems from doubts about her ability to deliver and manage childbirth pain [39]. Similarly, a study by Brunton et al. in Australia found that perceived parental self-efficacy was a predictor of pregnancy-related anxiety, with anxiety increasing as a mother’s confidence in her future parenting abilities decreased [1].
As articulated by Albert Bandura, self-efficacy—defined as a person’s belief in their ability to achieve desired outcomes—has a profound influence on behavior, motivation, and ultimately, success or failure. Bandura posits that self-efficacy is cultivated through four primary sources: mastery experiences, vicarious experience, verbal persuasion, and physiological and affective states. Therefore, recalling past successes, observing similar individuals who have achieved success through persistent effort, receiving verbal encouragement from others, and learning to manage stress in the face of life’s challenges can enhance self-efficacy [40].
Mohammadi et al. conducted a study among pregnant women attending comprehensive health centers in Isfahan. The primary aim of the study was to utilize Bandura’s four sources of self-efficacy to enhance self-efficacy related to pregnancy, childbirth, and parenting. The study then examined the impact of this intervention on postpartum depression, anxiety, and type of delivery. The findings indicated that training classes based on Bandura’s four sources of self-efficacy reduced postpartum depression and anxiety and increased the rate of vaginal deliveries. Therefore, it is recommended that healthcare centers offering prenatal services utilize Bandura’s self-efficacy theory to enhance childbirth self-efficacy, which may reduce pregnancy-related anxiety and improve the mental health of pregnant women [41].
In this study, however, no statistically significant correlation was found between perceived social support and pregnancy-related anxiety. Consequently, perceived social support was not a predictor of pregnancy-related anxiety. This finding is consistent with Neisani Samani et al., who also reported no significant relationship between anxiety and perceived social support in pregnant women conceived through assisted reproductive technologies [42].
Neisani Samani et al. explained the lack of a significant relationship between perceived social support and anxiety by noting that in Iranian culture, childbearing is highly valued as it contributes to family stability and marital satisfaction. Additionally, negative attitudes toward infertility are very prevalent. They further observed that due to this high cultural value placed on childbearing and the negative attitudes toward infertility, all participants had uniformly high levels of perceived social support. Consequently, because the level of social support was uniformly high across all participants, it was not possible to detect a significant relationship with anxiety. In other words, when all participants report high levels of support, there is insufficient variability to demonstrate a meaningful association with anxiety [42].
The lack of a significant correlation between perceived social support and pregnancy-related anxiety in the present study can be explained similarly to the study by Neisani Samani et al., as the mean score of perceived social support, particularly from family, was also high in our participants.
In the present study, maternal health literacy was not a predictor of pregnancy-related anxiety. Findings from the literature on the relationship between health literacy and pregnancy-related anxiety are inconsistent. For instance, a study by Uyanik et al. [43] reported that health literacy was a positive and significant predictor of pregnancy-related anxiety, with higher health literacy associated with increased pregnancy-related anxiety. In contrast to this finding, a study conducted in Japan demonstrated a positive effect of health literacy in reducing anxiety and depression among pregnant women [44]. These contradictory findings suggest that the relationship between health literacy and pregnancy-related anxiety is complex and likely influenced by contextual factors such as the type of measurement instrument, cultural background, and socioeconomic status. Therefore, further research using standardized tools and diverse populations is necessary to clarify the nature of this relationship.
One of the strengths of this study is that it simultaneously investigated the combined effect of four key cognitive-psychological variables, including depression during pregnancy, perceived social support, maternal health literacy, and childbirth self-efficacy, on pregnancy-related anxiety among pregnant women in Urmia City. Given the lack of previous research on this topic in this specific population, the findings can serve as a foundation for future studies, particularly interventional research aimed at reducing pregnancy-related anxiety by targeting its significant predictors (i.e., depression and childbirth self-efficacy). Another strength is the use of standardized and validated instruments, all of which have demonstrated acceptable validity and reliability in Iranian populations.
Among the limitations of the present study, first, the participants were limited to pregnant women covered by urban comprehensive health service centers in Urmia City, which restricts the generalizability of the findings to all pregnant women, especially those in rural areas or private care. Second, the cross-sectional design restricts causal inference between the cognitive-psychological variables and pregnancy-related anxiety. Third, this study used a self-reported questionnaire, and participants may not have provided fully accurate or truthful responses. To address this issue, several measures were implemented: all questionnaires were completed anonymously without collecting any identifiable information, and participants were assured of full confidentiality to encourage honest participation.
Conclusion
The current study revealed a moderate level of pregnancy-related anxiety among the study participants. Given the significant impact of anxiety on both maternal and fetal well-being, it is recommended that healthcare centers providing prenatal services incorporate early screening for pregnancy-related anxiety and its related factors into routine care. Furthermore, appropriate interventions should be implemented to reduce pregnancy-related anxiety by addressing its predictors, especially for vulnerable pregnant women. Considering that depression during pregnancy and childbirth self-efficacy were significant predictors of pregnancy-related anxiety among the women studied, it is recommended to incorporate strategies aimed at reducing depression and enhancing childbirth self-efficacy in all interventions designed to reduce anxiety and improve mental health among pregnant women. To achieve this objective, it is essential to leverage the knowledge, expertise, and experience of psychologists in healthcare centers that provide prenatal care. By identifying existing deficiencies, strategic measures can be implemented to enhance human resources and improve their capacity and competence within these centers.
Acknowledgements
The authors would like to thank Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran for supporting this project (Grant No: 11728). Additional thanks are extended to the Vice-Chancellor for Research and Technology at Urmia University of Medical Sciences, the Health Center of Urmia County, the participating urban comprehensive health service centers, and all participants who contributed to this investigation.
Authors’ contributions
MM initiated the study and conducted its conception and design. MMH was responsible for defining the intellectual content and conducting the literature search. Both MM and MMH contributed to the acquisition, analysis, and interpretation of the data. MM wrote and drafted the manuscript, while MMH reviewed and edited it. All authors read and approved the final manuscript.
Funding
This study was supported by funding from the Student Research Committee of Urmia University of Medical Sciences (Grant No: 11728). The funder of study had no role in the study design, data collection, data analysis, data interpretation, and preparation of the manuscript.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
All methods of this study were carried out in accordance with the Helsinki declaration. The ethical approval for the study was obtained from the Research Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1401.292). Informed consent was obtained from all individual participants included in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Brunton R, Simpson N, Dryer R. Pregnancy-related anxiety, perceived parental self-efficacy and the influence of parity and age. Int J Environ Res Public Health. 2020;17(18):6709. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hamzehgardeshi Z, Omidvar S, Amoli AA, Firouzbakht M. Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study. BMC Pregnancy Childbirth. 2021;21(1):208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ahmed Kadim M, Abdulameer Abdulrasol Z, Fadhil Obaid A, Ahmed Hamid H, Hamdi NH, Mousa NA. Assessment of Anxiety Among Pregnant Mothers. Iran Rehabilitation J. 2023;21(1):73–80. [Google Scholar]
- 4.Tarafa H, Alemayehu Y, Nigussie M. Factors associated with pregnancy-related anxiety among pregnant women attending antenatal care follow-up at Bedelle general hospital and Metu Karl comprehensive specialized hospital, Southwest Ethiopia. Front Psychiatry. 2022;13:938277. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Pearlstein T. Depression during pregnancy. Best Pract Res Clin Obstet Gynecol. 2015;29(5):754–64. [DOI] [PubMed] [Google Scholar]
- 6.Skouteris H, Wertheim EH, Rallis S, Milgrom J, Paxton SJ. Depression and anxiety through pregnancy and the early postpartum: an examination of prospective relationships. J Affect Disord. 2009;113(3):303–8. [DOI] [PubMed] [Google Scholar]
- 7.Nawabi F, Krebs F, Vennedey V, Shukri A, Lorenz L, Stock S. Health literacy in pregnant women: a systematic review. Int J Environ Res Public Health. 2021;18(7):3847. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Shikha D, Kushwaha P, Gokdemir O, Marzo RR, Bhattacharya S. Health literacy and disease prevention. Front Public Health. 2023;11:1128257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Huang J, Xu L, Xu Z, Luo Y, Liao B, Li Y, et al. The relationship among pregnancy-related anxiety, perceived social support, family function and resilience in Chinese pregnant women: a structural equation modeling analysis. BMC Womens Health. 2022;22(1):546. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Simon T, Fikadu K, Afework B, Alemu H, Kussia B. Childbirth Self-Efficacy and Its Associated Factors among Pregnant Women in Arba Minch Town, Southern Ethiopia, 2023: A Cross‐Sectional Study. J Pregnancy. 2024;2024(1):6478172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wernand JJ, Kunseler FC, Oosterman M, Beekman AT, Schuengel C. Prenatal changes in parenting self-efficacy: Linkages with anxiety and depressive symptoms in primiparous women. Infant Mental Health J. 2014;35(1):42–50. [DOI] [PubMed] [Google Scholar]
- 12.Verhelst P, Sels L, Lemmens G, Verhofstadt L. The role of emotion regulation in perinatal depression and anxiety: a systematic review. BMC Psychol. 2024;12(1):529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Kong H, Geng J, Wang Q, Zhu J, Zhao H. Exploring the mediating roles of stigma and perceived social support between health literacy and health care decision-making barriers among patients with cervical cancer. Asia-Pacific J Oncol Nurs. 2025;12:100716. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Trueba AF, Pluck G. Social support is related to the use of adaptive emotional regulation strategies in Ecuadorian adolescents in foster care. Psych. 2021;3(2):39–47. [Google Scholar]
- 15.Doménech P, Tur-Porcar AM, Mestre-Escrivá V. Emotion regulation and self-efficacy: The mediating role of emotional stability and extraversion in adolescence. Behav Sci. 2024;14(3):206. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Beal EM, Slade P, Krahé C. Cognitive processing biases associated with fear of childbirth. J Anxiety Disord. 2023;99:102761. [DOI] [PubMed] [Google Scholar]
- 17.Basharpoor S, Taherifard M. Predicting the pregnancy anxiety in pregnant women basing on cognitive biases and emotion regulation strategies. Iran J Psychiatric Nurs. 2019;7(2):23–31. (in Persian). [Google Scholar]
- 18.Rafiei N, Amini Rarani M, Eizadi F, Rafiey H, Seyedghasemi NS. Social support and its role in the prevention of depression and anxiety during pregnancy in Turkmen women. Int J Biomed Public Health. 2019;2(4):75–80. [Google Scholar]
- 19.Norozi E, Sharifzadeh G, Torshizi M, Gandomi F, Yousefzadeh A, Malaki-Moghadam H, et al. Predictors of pregnancy anxiety and its subscales in pregnant women in Birjand, Iran, in 2016. J Health Syst Res. 2017;13(3):373–80. (in Persian). [Google Scholar]
- 20.Kharazi SS, Peyman N, Esmaily H. An evaluation of the validity and reliability of the maternal health literacy and pregnancy outcome questionnaire. J Health Syst Res. 2017;12(4):512–9. (in Persian). [Google Scholar]
- 21.Rasouli P, Shobeiri F, Cheraghi F, Rasouli R, Ghanbari V. Study of the relationship of anxiety and depression in third trimester pregnancy on growth index of neonates and preterm delivery. Iran J Pediatr Nurs. 2016;2(4):1–9. (in Persian). [Google Scholar]
- 22.Mahdavy M, Kheirabadi G. The prevalence of postpartum depression and its related factors among women in Natanz city in 2018 (Iran). Qom Univ Med Sci J. 2020;14(2):78–85. (in Persian). [Google Scholar]
- 23.Montazeri A, Torkan B, Omidvari S. The Edinburgh Postnatal Depression Scale (EPDS): translation and validation study of the Iranian version. BMC Psychiatry. 2007;7(1):11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Hassanzadeh R, Abbas-Alizadeh F, Meedya S, Mohammad-Alizadeh-Charandabi S, Mirghafourvand M. Fear of childbirth, anxiety and depression in three groups of primiparous pregnant women not attending, irregularly attending and regularly attending childbirth preparation classes. BMC Womens Health. 2020;20:1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Bayrampour N, Nourizadeh R, Mirghafourvand M, Mehrabi E, Mousavi S. Psychometric properties of the pregnancy-related anxiety questionnaire-revised2 among Iranian women. Crescent J Med Biol Sci. 2019;6(3):369–74. [Google Scholar]
- 26.Bagherian-Sararoudi R, Hajian A, Ehsan HB, Sarafraz MR, Zimet GD. Psychometric properties of the Persian version of the multidimensional scale of perceived social support in Iran. Int J Prev Med. 2013;4(11):1277–81. [PMC free article] [PubMed] [Google Scholar]
- 27.Emadian SO. The effectiveness of positive thinking training on childbirth fear and childbirth self-efficacy in pregnant women in Sari. Appl Family Therapy J. 2022;3(2):482–95. (in Persian). [Google Scholar]
- 28.Khorsandi M, Jafarabadi MA, Jahani F, Rafiei M. Cultural adaptation and psychometric testing of the short form of Iranian childbirth self efficacy inventory. Iran Red Crescent Med J. 2013;15(11):e11741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Srinivasan A, Thambi SS, Krishnarajan D, Prakasam KCA. Incidence and impact of various complications on pregnancy related anxiety in women attending an obstetrics clinic in a tertiary care hospital. Indian J Pharm Pract. 2020;13(4):317–25. [Google Scholar]
- 30.Ghanbari-Homaie S, Hasani S, Mirghafourvand M. Correlation of anxiety with pregnancy symptoms and maternal-fetal attachment. Shiraz E-Medical J. 2022;23(5):1–8. [Google Scholar]
- 31.Al Ghadeer HA, Al Kishi NA, Almubarak DM, Almurayhil Z, Alhafith F, Al Makainah BA, et al. Pregnancy-related anxiety and impact of social media among pregnant women attending primary health care. Cureus. 2021;13(12):e20766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Langille C, Andreou P, Piccinini-Vallis H. The prevalence of pregnancy-specific perinatal anxiety in Nova Scotia. Matern Child Health J. 2023;27(7):1127–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Naja S, Al Kubaisi N, Singh R, Bougmiza I. Generalized and pregnancy-related anxiety prevalence and predictors among pregnant women attending primary health care in Qatar, 2018–2019. Heliyon. 2020;6(10):e05264. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Flink I, Al-Khafadji M, Ring S, Grundström H, Nieminen K, Ternström E, et al. Expecting the worst: pain catastrophizing and intolerance of uncertainty in women with fear of childbirth. J Psychosom Obstet Gynecol. 2025;46(1):2507400. [DOI] [PubMed] [Google Scholar]
- 35.Nath A, Venkatesh S, Balan S, Metgud CS, Krishna M, Murthy GV. The prevalence and determinants of pregnancy-related anxiety amongst pregnant women at less than 24 weeks of pregnancy in Bangalore, Southern India. Int J Women’s Health. 2019;11:241–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Khodakarami B, Golalizadeh Bibalan F, Soltani F, Soltanian A, Mohagheghi H. Impact of a counseling program on depression, anxiety, stress and spiritual intelligence in pregnant women. J Midwifery Reproductive Health. 2017;5(2):858–66. [Google Scholar]
- 37.Lebel C, MacKinnon A, Bagshawe M, Tomfohr-Madsen L, Giesbrecht G. Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. J Affect Disord. 2020;277:5–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Jimenez-Barragan M, Del Pino Gutierrez A, Curto Garcia J, Monistrol-Ruano O, Coll-Navarro E, Porta-Roda O, et al. Study protocol for improving mental health during pregnancy: a randomized controlled low-intensity m-health intervention by midwives at primary care centers. BMC Nurs. 2023;22(1):309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Nikbakht MF, Sadeghi AH, Amini L, Haghani S. The study of relationship between childbirth selfefficacy and attitude toward normal delivery with pregnancy anxiety in primigravida women referred to selected health care centers of Shahriar city in 2018. Nurs Midwifery J. 2020;18(3):210–22. (in Persian). [Google Scholar]
- 40.Tschannen-Moran M, McMaster P. Sources of self-efficacy: Four professional development formats and their relationship to self-efficacy and implementation of a new teaching strategy. Elementary School J. 2009;110(2):228–45. [Google Scholar]
- 41.Mohammadi F, Kohan S, Farzi S, Khosravi M, Heidari Z. The effect of pregnancy training classes based on Bandura self-efficacy theory on postpartum depression and anxiety and type of delivery. J Educ Health Promotion. 2021;10:273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Neisani Samani L, Chehreh H, Seyed Fatemi N, Hosseini F, Karamelahi Z. Relationship between perceived social support and anxiety in pregnant women conceived through assisted reproductive technologies (ARTs). Iran J Nurs. 2016;29(103):51–9. (in Persian). [Google Scholar]
- 43.Uyanik A, Koç G, Ardiç M. The effect of pregnancy health literacy on risk perception in pregnancy and pregnancy anxiety. BMC Pregnancy Childbirth. 2025;25(1):664. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Haruyama Y, Miyagi E, Kobashi G, Obata S, Umazume T, Yoshimi A, et al. Impact of health literacy on anxiety and depressive symptoms in pregnant women in Japan during the COVID-19 pandemic. Sci Rep. 2022;12(1):14042. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.