Women’s outcome instrument for maternal health care (WOICE) of Iranian pregnant women after 35: A cross-sectional study

Abstract

BACKGROUND:

Exploring the health dimensions of pregnant women over 35 opens a window into a deeper understanding of the physical and psychological challenges of this critical period and paves the way for targeted interventions. This study aimed to make the voices of pregnant women aged 35 and older heard.

MATERIALS AND METHODS:

This study was conducted in 2024 at three major hospitals in Tehran. The sample size consisted of 300 pregnant women. The participants were selected from among pregnant women older than 35 years. We utilized the women’s outcome instrument for maternal health care instrument, which was developed by the World Health Organization (WHO). Data analysis was performed using SPSS (Version 22).

RESULTS:

The participants, with a mean age of 38.37 ± 2.61 years, were included in the study. Most had more than a high school education (65%). 36.7% reported sexual dissatisfaction. The overall rate of anxiety was 28.9%, while 25% showed symptoms of depression. Additionally, 3.6% had experienced violence, 3.3% of participants had a history of substance abuse or smoked cigarettes, and 2.3% reported impaired functioning. Furthermore, 38.5% reported a medical condition or other health problem.

CONCLUSION:

Considering the results of the study and the problems of pregnant women in the field of maternal complications in pregnant women over 35 years of age, it seems that policymakers should make the necessary revisions in the policies and laws of the youth population to meet the needs of physical health, care facilities, and improve social support and counseling specific to pregnant women and the necessary training for spouses.

Introduction

Iran is among the nations that have experienced a significant decline in fertility rates. According to data from the Statistical Yearbook of Iran's National Organization for Civil Registration, the age pattern of childbearing in Iran is shifting toward older ages.[1] The decision to delay childbirth is becoming increasingly common among global populations, as individuals pursue economic independence, career aspirations, stable housing, and improved lifestyle attributes.[2] The population undergoing assisted reproductive technology (ART) and frozen embryo transfer is increasing[2]; despite these technological developments that contribute to a widening window of female reproductive capacity, maternal age remains an important factor with varying effects on maternal and fetal/infant health. In both developed or developing countries, aging populations pose challenges in all aspects. To respond to such challenges, some countries have tailored intervention strategies that are appropriate to their country’s circumstances. To develop intervention strategies to reduce maternal complications in women over 35, it is essential to hear the voices of these women.[3]

Pregnancy in women over 35 years of age, previously identified as a high-risk pregnancy based on medical literature and research, has been reclassified outside the high-risk category under Iran’s new “Law on Family Support and Youthfulness of the Population.” According to this law, pregnancy over 35 is not inherently risky, and women in their late thirties and even fifties can experience successful pregnancies with favorable prognoses. While this shift aims to encourage childbearing, it may cause confusion and anxiety among expectant mothers over 35.

A study conducted in Brazil on pregnant women over 35 years of age showed that these women felt that they were provided with little healthcare and had little information about the risks of pregnancy at an older age.[4] Also, in 2019, a study was conducted in Iran on the unmet healthcare needs of pregnant women, and one of the highest unmet needs was related to obstetric services at 15.6%.[5] Review of studies suggests that adequate prenatal care, proper management during pregnancy and delivery, would make the pregnancy prognoses at older ages similar to those of young pregnant women, and positive outcomes are expected from these pregnancies.[6,7] Studies dealing with advanced maternal age have mainly focused on the relationship between age-related risks and adverse outcomes.[6,8,9,10]

In 2012, the maternal morbidity workgroup (MMWG) of the World Health Organization (WHO) designed the WOICE tool to assess pregnancy-related complications. women’s outcome instrument for maternal health care presents a new approach to measuring non-severe maternal morbidities and allows health specialists to have a wider understanding of women beyond clinical conditions.[11] So far, the prevalence of non-severe maternal morbidities among pregnant women, especially conditions related to domestic violence, sexual violence, and changes in psychological health, social role, and performance, has remained largely unknown.[12,13]

Despite the overall decline in fertility rates in most age groups, rates in older women have increased.[1] Also, considering the passage of 3 years since the enactment of the Youth Population Law, a review of this law showed that the third child pattern has increased by 9%, the fourth child pattern by 28%, the fifth child pattern by 51%, and the fertility rate of mothers over 35 years of age has increased by 15%.[14] Recent demographic shifts, including a 15% rise in fertility rates among women over 35 following the implementation of the Youth Population Law, underscore the urgent need to understand the unique challenges faced by this growing population of pregnant individuals.[14] This increase, coupled with a persistent lack of data on the effects of domestic violence, sexual violence, and related psychological and social impacts (5, 16, 17), highlights a critical gap in our understanding of maternal health.[12,13] Thus, this study was done to examine the maternal complications during pregnancy in women above 35 years of age using the WHO-WOICE instrument in Iran.

Materials and Methods

Study design and setting

This cross-sectional study was conducted in 2024 at three major hospitals in Tehran to assess the WOICE of Iranian pregnant women after 35. Data were collected from July 26, 2024, to November 28, 2024. Participants were randomly selected through stratified sampling using a simple lottery method.

Study participants and sampling

Three hundred pregnant women above 35 years of age, referring to Shahid Akbar Abadi, Mahdieh, and Imam Khomeini Hospitals, were invited to participate in the study. The inclusion criteria were pregnant women above 35 years of age, the third trimester of pregnancy, Iranian nationality, minimum literacy of reading and writing, non-exposure to significant stressful events over the last six months (such as accidents, serious disease, or loss of beloved ones), mother not suffering from an established psychological disorder (according to the women’s self-expression), while the exclusion criterion was lack of willingness to answer all questions.

Data collection tools and techniques

After the informed consent form was signed, sampling began. Each interview lasted 30 to 40 min. In addition to the interview, the patient’s medical records were reviewed to confirm clinical data. Before conducting the interview, the objectives of the study, the duration of the interview, the confidentiality of the information, and the voluntary nature of the process were explained. The interviews were conducted using demographic, WOICE, and domestic violence questionnaires in a separate room, respecting the privacy of the individuals, and factors such as appropriate environmental conditions and an examination bed were considered. The examinations were also performed by the researcher according to the requirements of the WOICE questionnaire. At the end of the interview, 10 min was allowed to answer the individuals’ questions to comply with ethics. The WOICE questionnaire was completed after the prenatal care visit and did not interfere with the women’s medical care.

The minimum sample size was determined based on the following calculation and is consistent with findings from similar studies, which involved 300 participants.[15]

n = 300

α = 05 z = 1.96

P = 0.8 d = 0.04

The WOICE framework includes multiple assessment instruments: the WHO Disability Assessment Schedule-12 (WHODAS-12), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and the Women’s Abuse Screening Tool (WATS).

• WHODAS-12: This instrument evaluates the ability to perform daily tasks and fulfill social responsibilities. In alignment with previous studies, a score of ≥37.4 on WHODAS-12 is indicative of significant dysfunction, establishing the 95^th percentile as a cutoff point.[16] It encompasses six domains: cognition, mobility, self-care, social interaction, life activities, and participation. The validity and reliability of various components of this questionnaire have been previously assessed in Iran, with WHODAS-12 demonstrating a Cronbach’s alpha of 0.93 based on a sample of 255 subjects.[17]

• GAD-7 and PHQ-9: These questionnaires are used to detect anxiety and depression, respectively. A score of 10 or higher on either instrument is required to indicate significant anxiety or depressive symptoms.[18,19] The GAD-7 has been validated with a Cronbach’s alpha of 0.85 from a sample of 199 participants,[20] whereas the PHQ-9 displayed a Cronbach’s alpha of 0.85 based on a study involving 463 subjects.[21]

• ASSIST: This alcohol and drug use screening tool has been piloted across several provinces and involved a sample size of 2600 participants, achieving a Cronbach’s alpha ranging from 0.79 to 0.95.[22]

• WATS: The choice of the domestic violence questionnaire was determined by the research team, opting for the WATS. The reliability and validity of the WATS questionnaire were assessed with a sample of 80 individuals, yielding a Cronbach’s alpha of 0.84.[23]

The reliability of the WOICE questionnaire was validated by 20 experts in the field. The Cronbach’s alpha coefficient of this questionnaire, internal consistency, and content validity are 0.89, 0.95, and 0.72, respectively.

Ethical consideration

The present study was approved by the ethics committee at the faculty of nursing and midwifery—Shahid Beheshti University of Medical Sciences under ethics code IR.SBMU.PHARMACY.REC.1401.106. The study was conducted in accordance with humane ethical standards in accordance with the Declaration of Helsinki.

Statistical analysis method

Data analysis was performed using SPSS (Version 22). In this study, descriptive statistics were used to analyze the data. Descriptive statistics, including frequency and percentage, mean and standard deviation, were used to describe demographic and obstetric characteristics, sexual function, anxiety, and depression. Regression analysis was used to examine the correlation between different dimensions of the questionnaire.

Results

This study was conducted in three Level 3 hospitals, Imam Khomeini, Mahdieh, and Shahid Akbar Abadi, involving a sample size of 300 pregnant women aged 35 years and older. The participants had a mean age of 38.37 ± 2.61 years, and the mean gestational age was calculated to be 32 weeks and 4 days (see Table 1).

Table 1.

Demographic and clinical condition characteristics (n=300)

Variable		Number (%)
Maternal age		Mean±SD 38/37±2/61
Gravida		G1 45 (15%) G2 67 (22/3%) G3 104 (34/7%) G4≤84 (28%)
Parity		P0 74 (24/7%) P1 98 (32/7%) P2 95 (31/7%) P3 21 (7%) P4≤12 (4%)
Live child		L0 80 (26/7%) L1 100 (33/3%) L2 94 (31/3%) L3 17 (5/7%) L4 ≤9 (3%)
Unwanted pregnancy		Yes 75 (25%) No 225 (75%)
Multiple pregnancy		Yes 25 (8/4%) No 275 (91/6%)
Use of assisted reproductive technologies		Yes 36 (11/7%) No 264 (88/3%)
Prepregnancy visit		Yes 130 (43/6%) No 170 (56/4%)
Mode of delivery		NVD 99 (33%) C/S 138 (46%)
Mother’s education		Illiterate 0 (0%) Primary or less 45 (15%) Secondary 60 (20%) Higher 195 (65%)
Mother’s job		Housewife 261 (87%) Employee 19 (6/4%) Worker 2 (0/7%) Self-employed 17 (5/7%)
Husband’s education		Illiterate 0 (0%) Primary 37 (12/7%) Secondary 93 (32%) Higher 156 (53/6%)
Husband’s job		Employee 59 (20/4%) Manual worker 77 (26/6%) Self-employed 148 (51/2%) Unemployed 5 (1/7%)
Overall health rating		Very good 23 (7/9%) Good 112 (38/5%) Neither poor nor good 127 (43/6%) Poor 22 (7/6%) Very poor 7 (2/4%)
Have you been told you have anything wrong/any medical condition(s)?		Yes 115 (38/5%) No 184 (61/5%)
Are you taking any medication(s)?		Yes 111 (37%) No 189 (63%)
Any preexisting conditions		Yes 133 (44/3%) No 167 (56/7%)
Leading direct preexisting conditions		Gestational diabetes 80 (60/1%) Gestational hypertension 18 (13/5%) Hypothyroidism 15 (11/2%) Preeclampsia 8 (6%) Others 12 (9/2)

SD=Standard deviation, NVD=Normal vaginal delivery, C/S=cesarean section

The study showed the following results: anxiety 28/9%, depression 25%, environmental risk factors 3/3%, function (WHODAS-12) 2/3%, domestic violence 1/7%. Baseline clinical conditions were assessed using the question: “Have you been told you have anything wrong/any medical condition(s)?” Among the respondents, 38.5% reported at least one problem diagnosed by a physician during their pregnancy, while 10% indicated they had more than one reported condition.

Clinical symptoms experienced by the pregnant women over the previous two weeks included the following: 31.3% reported back pain, 28.7% experienced muscle cramps, 27% reported nausea, 26% experienced headaches, 16.4% reported abdominal discomfort or pain, 11% had respiratory issues, and 10% reported vomiting as well as anal pain and pressure.

By investigating the details about the clinical conditions, 44.3% responded affirmatively to the question “Do you have any underlying conditions?”, while 6.7% did not report any disease history The details regarding the clinical conditions are as follows: gestational diabetes mellitus 39/7%, gestational hypertension 14/3%, hypothyroidism 7%, anemia 6/5%, preterm labor 5%, preeclampsia 4/3%, intrauterine growth restriction 3/7%, cholestasis 3/5%, premature rupture of membranes 3/5%, placenta previa 3/5%, urinary tract infection 1/7%.

To investigate environmental risk factors, participants were asked about their use of various substances, including cigarettes, alcoholic drinks, marijuana, inhalants, sedatives or sleep aids, hallucinogens, and other drugs of abuse. Among the participants, 3.3% reported using these substances during pregnancy. Furthermore, 0.3% indicated that their substance use had led to social, health, and financial issues.

In addition, 3.6% of women reported experiencing feelings of fear or physical violence from their spouse. This statistic pertains to those who answered affirmatively to the questions: “Has your husband ever physically harmed you?” and “Has your husband’s words or actions ever caused you to feel fearful?”.

After analyzing the data concerning sexual activity during pregnancy, we discovered that 45.3% of women reported ceasing sexual relationships during this period (see Table 2).

Table 2.

Sexual life in pregnant women over 35 years (n=300)

Variable		Number(%)
Sex life during pregnancy?		No 134 (45/3%) Yes 161 (54/4%)
Reason for sexual abstinence?		Does not have partner currently 5 (3/6%) Medical restriction 54 (39/1%) Partner does not want to 3 (2/2%) She has little or no interest in sex 11 (8%) Worrying about abortion 59 (42/8%) Refused to answer 5 (3/6%)
Satisfaction with sex life?		No 91 (30/3%) Yes 209 (69/6%)
Reason for sexual dissatisfaction?		Little or no interest in sex 60 (65/9%) Decreased genital sensation (feeling) 3 (3/2%) Decreased vaginal lubrication (dryness) 6 (6/5%) Problem reaching orgasm 8 (8/7%) Pain during sex 14 (15/3%)

In examining the correlation between different areas of the questionnaire, it was found that the inability to function is positively related to violence, depression, and anxiety. Violence is also positively related to anxiety and depression, and depression and anxiety are directly related to each other.

Discussion

The purpose of this study was to hear the voices of pregnant women aged 35 and older. This cross-sectional study revealed significant levels of medical conditions, anxiety, and depression among the participants.

The WOICE assessment revealed that 38.5% of women had at least one medical condition, indicating a high burden of physical and health problems in this age group. This rate was reported as 66% in another study.[24]

Supporting these findings, a similar study conducted in Brazil at a referral healthcare center also reported high levels of anxiety and depression as primary outcomes.[24] Also, a 2025 study by Benyian[25] in Iraq on pregnant women showed that most of the study participants had mild to moderate anxiety. This underscores a consistent trend of mental health challenges faced by pregnant women across different cultures and settings. Given that pregnancy over the age of 35 is considered high-risk, a qualitative study reported that high-risk pregnancy was associated with sociocultural and economic problems, increased financial needs, and negative feelings such as doubt, fear, concern, insecurity, and anxiety.[26] A study conducted in 2022 indicated that one of the highest unmet needs in healthcare pertains to psychological services, with a striking 43.2% of individuals reporting this gap.[5] Research by Brunton et al. further supports that pregnant women aged 35 years and older report substantially higher levels of anxiety compared to their younger counterparts aged 20 to 30.[27] While women in this older age group may generally be more emotionally prepared for motherhood, the experience of pregnancy after 35 can still give rise to heightened anxiety, highlighting the complex interplay between age, emotional readiness, and the challenges of pregnancy.

The results of the study showed that 25.8% of participants suffered from depression. The findings from this study align with a growing body of literature that indicates an increased risk of depression associated with advanced maternal age.[10,28] This increased risk has been attributed to a variety of factors, such as the perception that older women lack peer support due to deviating from social norms.[29] Moreover, cultural shifts have led to a societal emphasis on smaller family sizes, with a prevailing belief that societal attitudes are unfavorable toward larger families.[30] This has resulted in having fewer children being perceived as a value or norm within Iranian society.[30] Many individuals are now making reproductive choices based on current economic and social conditions, as well as their personal circumstances.[30] Abdollahi and Rahimi[30] highlight that the prevalence of social issues, alongside concerns for the future well-being of children, contributes to a sense of despair and economic insecurity within society. Screening mothers during this period and providing free counseling in the health system until recovery are effective and beneficial measures that are increasingly needed. However, many barriers hinder the referral and follow-up processes for Iranian pregnant women seeking counseling services. A study conducted by Jafari in 2021 identified several obstacles, including a lack of awareness about available services, concerns regarding confidentiality, issues related to accessibility (such as distance and inadequate facilities for counseling sessions), inconvenient operating hours, and delays in referrals.[31]

Furthermore, 3.6% of women reported experiencing fear or physical violence from their spouses. Similar findings have been documented in other studies, confirming the troubling prevalence of domestic violence.[15,32] A 2023 study involving pregnant women in Isfahan reported alarming figures: psychological violence was identified in 74.4% of cases, and physical violence in 14.9%.[33] One significant challenge in detecting domestic violence is that many violent actions are perceived as normal or acceptable within certain cultural contexts, complicating the recognition of such behaviors as abusive or harmful.[34] Mengistie and Semahegn[35] highlighted that a substantial portion of women—eight out of ten—accepted the notion of being beaten by a man if there was perceived justification. Additionally, one out of 20 women endorsed traditional gender norms that support male violence. Fear can deter women from seeking help and make healthcare professionals hesitant to intervene in suspected cases of abuse.[36] Victims may worry about retaliation from their abuser or doubt that their concerns will be taken seriously, and healthcare specialists may face their own fears regarding potential legal or professional repercussions or may feel uncertain about how to appropriately respond to such situations.[36,37]

Studies indicate that a reduction in sexual activity during the prenatal period can be attributed to various factors, including maternal complications, physiological changes, lack of information about sexual desire during pregnancy, and cultural behaviors.[38,39] Notably, 42.8% of participants who had ceased sexual relations during pregnancy cited fear of abortion or premature delivery as their primary concern, a finding that is consistent with similar research.[39] Despite the reduction in sexual activity, a significant majority of the participants (69.3%) reported satisfaction with their sexual life. This suggests that many women do not require sexual intercourse to achieve sexual satisfaction. In contrast, a study conducted in Morocco found that 61% of urban women expressed dissatisfaction with their sexual lives, and only 33.2% continued sexual intercourse throughout their pregnancy.[40] This is notably lower than the 45% observed in the present study, indicating regional differences in sexual practices and attitudes during pregnancy. Additionally, a review study showed that most couples do not have the necessary information about sexual relationships during pregnancy, which can lead to numerous relationship issues.[41] Providing accurate information and advice from trained professionals can dispel misconceptions, demystify beliefs about sexuality, and improve the sexual performance of couples during pregnancy.[42] Santhoshkumari and Sharmil[43] in a systematic review on the efficacy of educational interventions in the management of obstetric complications, revealed the results showed that through education and also by providing sufficient resources, time, and coordination with obstetric specialists, nurses and midwives will be able to implement their care roles, which include proper diagnosis, appropriate intervention, advanced care, client education, and psychological support.

The study also evaluated performance among participants, revealing that only 2.4% reported impaired performance. This figure is notably lower compared to some other studies,[24] although a similar study in 2021 reported comparable results.[15] A 2020 study conducted in three countries, Kenya, Jamaica, and Malawi, also found that participants over the age of 35 with a physical health problem were more likely to have lower levels of functioning than those without any problems.[44] According to the results of another study conducted in 2020, there is no evidence that there is a sudden and sharp increase in the risk of disability at the age of 35; in fact, the process of disability is much more complex and varies from person to person.[45] The findings indicate that during pregnancy, women primarily experience moderate to severe difficulties in the areas of mobility (such as standing for extended periods and walking) and participation (engaging in social activities, being emotionally affected by health problems). A similar study conducted in Brazil on pregnant women also demonstrated that mobility performance tends to weaken in the third trimester,[15] aligning with the results of the present study. Additional studies may provide more comprehensive insights into the specific challenges pregnant women face in terms of performance and mobility.

This study found that individuals’ functional impairment was directly related to violence, depression, and anxiety. A 2018 study found that both maternal depressive symptoms and pregnancy-related anxiety symptoms were associated with reduced maternal functioning.[46] Cross-sectional data from an urban sample of women in the third trimester showed that the mean WHODAS score was associated with mental health, and anxiety and depression were associated with significant loss of functioning.[44] Another finding of this study was the positive association of domestic violence with anxiety and depression. This finding is consistent with other studies.[32,47] In fact, domestic violence has been identified as a chronic stressful situation that increases the risk of depression and anxiety during pregnancy.[47] The study also found a correlation between depression and anxiety, which has been reported in other studies.[48] This correlation is positive, indicating the importance of targeting depression and anxiety for screening in pregnancy. Figure 1 shows the relationship between maternal health needs and improving maternal and fetal health.

Figure 1.

Conceptual figure

The WOICE assessment underscores the critical need to actively listen to women’s voices during prenatal care. Policymakers need to ensure that mental health services are culturally sensitive and accessible to all pregnant women, regardless of socioeconomic status. Also, create a more supportive environment for pregnant women and improve maternal and infant health outcomes in this high-risk population, and consider educational materials to address common concerns about sexual activity during pregnancy.

Limitations and recommendations

One of the strengths of the present study has been a large sample size, which would enhance the generalizability of the research results. The WHO-WOICE instrument evaluates many aspects. Nevertheless, some of them do not have more details, such as drug abuse (including any type of drug) and violence, without knowing the previous history of violence or psychological violence. Another issue is the duration of filling the questionnaire, which is a constraining factor for implementation in typical healthcare provision. The spatial limitation of the research, which constrained the sampling to level III hospitals, is another limitation that may limit the generalizability of the results.

Future research is recommended to compare pregnant women before and after 35 years of age using the WHO-WOICE tool.

Conclusion

Considering the results of the study and the problems of pregnant women in the field of maternal complications in pregnant women over 35 years of age, it seems that policymakers should make the necessary revisions in the policies and laws of the youth population to meet the needs of physical health, care facilities, and improve social support and counseling specific to pregnant women and the necessary training for spouses.

Abbreviations

ART: Assisted reproductive technology; DALYs: Disability-adjusted life years; GAD-7: General Anxiety Disorder-7; MMWG: Maternal morbidity workgroup; PHQ-9: Patient Health Questionnaire-9; WHO: World Health Organization; WHODAS-12: WHO Disability Assessment Schedule-12.

Ethical considerations

The ethics committee of Shahid Beheshti University of Medical Sciences approved the study (IR.SBMU.PHARMACY.REC.1401.106).

Before the study, the research objectives and the confidentiality of all the information were explained to participants. All participants signed informed consent forms, and the researcher sought to protect all financial and intellectual rights of the research samples.

Author’s contributions

MH conducted data collection, contributed to data analysis and interpretation, drafted the manuscript, wrote and reviewed the article; ZK administrated and designed the study, reviewed the prepared manuscript; SH T contributed to designing; NE contributed to analyzing and interpretation of the data; and MN analyzed and interpreted data. All authors read and approved the final manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.