Abstract
Background/purpose
Due to the importance of social support in pregnant women, especially those with gestational diabetes that cause anxiety and stress in them and requires effective and enough attention, this study aims to assess perceived social support of pregnant women with gestational diabetes in western Iran compared to healthy controls and its relationship with their perceived anxiety.
Methods
This is a descriptive/analytical study with a cross-sectional design conducted on 180 pregnant women with gestational diabetes (n = 89) and without gestational diabetes (n = 91) referred to the obstetrics and gynecology clinics of two hospitals (Asalian and Shahid Rahimi) in Khorramabad, western Iran. Data collection tools were a demographic checklist, the Multidimensional Scale of Perceived Social Support (MSPSS), and the Beck Anxiety Inventory (BAI). Collected data were analyzed in SPSS v.20 software using chi square test, independent t-test, one-way ANOVA, and Pearson correlation test.
Results
The difference between the two groups was significant in terms of perceived support from family (p = 0.001), perceived support from friends (p = 0.006), and anxiety (p = 0.047). Pearson correlation test results showed a significant negative relationship between the scores of MSPSS and BAI in patients (r= -0.329, p = 0.001) and controls (r=-0.204, p = 0.006). There was a significant difference in the MSPSS score among diabetic women in terms of having fetal macrosomia (p = 0.005), occupation (p = 0.003), education (p = 0.001), and frequency of pregnancy (p = 0.010).
Conclusions
The perceived social support level is higher in diabetic pregnant women compared to healthy peers in western Iran. Improvement of social support from family and friends can reduce the anxiety of pregnant women with/without diabetes.
Keywords: Social support, Anxiety, Gestational diabetes, Pregnancy
Introduction
Diabetes is a group of metabolic disorders of carbohydrate metabolism characterized by high blood glucose levels affecting more than 422 million adults worldwide. There were 1.5 million deaths in 2012 directly related to diabetes, according to the most recent data reported by the World Health Organization [1]. The incidence of gestational diabetes has doubled over the last 6–8 years. Gestational diabetes is a type of diabetes that can develop during pregnancy in women with no previous history of diabetes. Insulin resistance as a result of late metabolic changes in pregnancy increases the need for insulin and can cause impaired glucose tolerance or type 2 diabetes which is similar to gestational diabetes. Its reported prevalence varies from 1 to 45% of all pregnancy cases worldwide [2]. Prevalence of gestational diabetes varies depending on the study population, and the used diagnostic criteria. Jafari-Shobeiri et al. [3] in a systematic review in 2015, reported the prevalence of gestational diabetes in Iran as 3.41% (ranging from 1.3 to 18.6%). Different factors affect the development of gestational diabetes in Iran such as gestational age, history of gestational diabetes, family history of diabetes, body mass index, abortions and parity, and history of macrosomia [3, 4].
During pregnancy, women are prone to experiencing psychological problems such as anxiety [5]. Pregnancy anxiety is a maternal psychological disorder that is defined as anxiety related to childbirth, maternal and neonatal health. Severe anxiety during pregnancy disrupts mother-infant relationship and reduces the maternal role [6]. It is associated with an increased overall risk for prematurity, low birth weight [7, 8] or suicidal tendency [9]. One of the most important factors that can reduce anxiety and stress during pregnancy is social support [10–12], which refers to “provision of psychological and material resources intended to benefit an individual’s ability to cope with stress” [13]. Social support can come from many resources, such as family, friends, and significant others. Lack of social support is an important risk factor for maternal well-being during pregnancy and has adverse effects on pregnancy outcomes [14]. The role of the spouse (male) as a key member of the family is important. Perceived social support plays a mediating role between anxiety symptoms and life satisfaction among pregnant women [15]. It is a protective factor against anxiety disorders in pregnant women with a positive effect on mental health [16]. Perceived social support refers to how individuals perceive friends, family members and others as sources available to provide material, psychological and overall support during times of need [17].
Pregnancy is one of the critical periods in women in which the need for social support is felt more than ever. The psychological health of pregnant women in low- and middle-income countries such as Iran is probably more worrisome. We found no study on the perceived social support of pregnant women with gestational diabetes and its relationship with perceived anxiety in western Iran with low-income and less developed cities. In one similar study, Momeni Javid et al. [18] showed that pregnant women with gestational diabetes in Tehran (northern Iran) had less social support and perceived stress. Considering cultural differences between Khorramabad and Tehran cities and the importance of conducting more studies to fill the research gap, and given that anxiety symptoms are common during pregnancy and may cause serious adverse consequences and requires effective and enough attention, this study aims to assess perceived social support of pregnant women with gestational diabetes living in Khorramabad city compared to healthy controls and its relationship with their perceived anxiety. This article aims to verify the following assumptions among pregnant women:
Perceived social support is different between pregnant women with and without gestational diabetes in western Iran;
Perceived social support is associated to perceived anxiety during pregnancy;
Demographic and obstetric factors affect perceived social support of pregnant women with gestational diabetes in western Iran.
Materials and methods
Study design and samples
This is a descriptive/analytical study with a cross-sectional design. Participants were 200 pregnant women (100 diagnosed with gestational diabetes and 100 non-diabetic). Patients were selected after diagnosis using a census method from among pregnant women referred to the obstetrics and gynecology clinics of two hospitals (Asalian and Shahid Rahimi) affiliated to Lorestan University of Medical Sciences in Khorramabad, western Iran in 2019, while healthy women were selected using a convenience sampling method from those referred to the two mentioned hospitals. The two groups were matched for age. The gestational diabetes in women was diagnosed based on the results of 2-hour 75 g oral glucose tolerance test, fasting blood sugar ≥ 92 mg/dL, blood sugar level ≥ 180 mg/dL 1 h after a meal, or blood sugar level ≥ 153 mg/dL 2 h after a meal. The inclusion criteria were: Having gestational diabetes based on the mentioned criteria (for patients), consent to participate in the study, and no mental illness. Exclusion criteria were: lack of reading and writing literacy, return of incomplete questionnaires, having other known diseases (e.g. Asthma, cardiovascular disease, or pregestational diabetes), and taking steroids or drugs affecting glucose level in patients. Based on these criteria, the data of 11 patients and 9 controls were excluded from the study due to returning incomplete questionnaires. Therefore, the final sample size was 180 (89 patients and 91 controls). After obtaining permissions from the clinics and a written informed consent from the participants, the questionnaires were then distributed among them.
Measures
A checklist was first used to survey demographic and obstetric information of samples including age, occupation, education, body mass index (body weight in kg divided by body height in m2), family history of diabetes, history of abortion, history of hypertension, history of stillbirth, history of fetal macrosomia, frequency of pregnancy, pregnancy trimester, receiving prenatal care. The Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire developed by Zimet et al. [18] was used to assess the perceived social support of samples. It is a 12-item scale to measure perceived social support from three sources: Family, Friends, and Significant Others. The items are rated on a 7-point Likert scale form 1 = Very strongly disagree to 7 = Very strongly agree. The total score ranges from 12 to 84. Higher scores show higher social support. We used the Persian version of MSPSS localized by Bagherian-Sararoudi et al. [19]. They reported a Cronbach’s α coefficient of 0.84 for the whole questionnaire, and 0.90, 0.93 and 0.85, for the friends, significant others and family subscales, respectively, and concluded that it is a reliable, valid and acceptable measure of perceived social support of Iranian population. Moreover, the Beck Anxiety Inventory (BAI) developed by Beck et al. [20] was used to assess the clinical anxiety of samples. It has 21 self-reported items rated on a 4-point scale from 0 (not at all) to 3 (severely) to assess the severity of anxiety symptoms during the past week. The total score ranges from 0 to 63; score 0–7 show minimal anxiety; 8–15, mild anxiety; 16–25, moderate anxiety; and 26–63, severe anxiety. We used the Persian version of BAI prepared by Kaviani and Mousavi [21] who showed that the Persian BAI has a good reliability (r = 0.72), a very good validity (r = 0.83), and an excellent internal consistency (α = 0.92) to be used on Iranian population. The questionnaires were completed through an interview with the participants after obtaining a written informed consent from them and explaining the study objectives and process to them. They were assured of the confidentiality of their information and were free to leave the study at any time.
Data analysis
After collecting data, they were analyzed in SPSS v.20 software using descriptive statistics (frequency, percentage, mean, standard deviation), chi square test (to compare the two groups in terms of demographic/obstetric factors), independent t-test (to compare the two groups in terms of study variables), one-way ANOVA (to compare pregnancy trimester, frequency of pregnancy, BMI, and education of patients), and Pearson correlation test (to examine the correlation between MSPSS and BAI score in the two groups). The significance level of all tests was set at 0.05.
Results
The mean age of patients was 32.35 ± 6.49 years, and for controls it was 31.17 ± 6.07 years. Most of patients had high school diploma (n = 36,40.4%), a body mass index (BMI) ≥ 30 kg/m2 (n = 42, 47.2%), were housewives (n = 82, 92.1%), had no history of abortion (n = 70, 78.7%), stillbirth (n = 86, 96.6%), fetal macrosomia (n = 75,84.3%), hypertension (n = 77, 86.5%); had a family history of diabetes (n = 48, 53.9%), were at the third pregnancy trimester (n = 67, 75.3%), had received prenatal care (n = 64, 71.9%), and were first-time mothers (n = 27, 30.3%). In the control group, most of mothers had high school diploma (n = 41,44.1%), a BMI ≥ 30 kg/m2 (n = 37, 40.7%), were housewives (n = 87, 95.6%), had no history of abortion (n = 73, 80.2%), stillbirth (n = 8, 96.7%), fetal macrosomia (n = 83,91.2%), hypertension (n = 83, 91.2%); had no family history of diabetes (n = 71, 78%), were at the third pregnancy trimester (n = 76, 83.6%), had received prenatal care (n = 71, 78%), and were first-time mothers (n = 38, 41.8%). For more information, see Table 1. The results of Chi square test showed that the difference between groups in terms of demographic factors was significant only in family history of diabetes (p = 0.001).
Table 1.
Demographic and obstetric characteristics of the participants and the results of chi square test
| Characteristics | Patients (n = 89) | Controls (n = 91) | Sig.* | |||
|---|---|---|---|---|---|---|
| % | N | % | N | |||
| Age (year) | ≤ 30 | 38.2 | 34 | 42.9% | 39 | 0.213 |
| > 30 | 61.8 | 55 | 57.1 | 52 | ||
| Education | Lower than high school education | 24.7 | 22 | 30.7 | 28 | 0.103 |
| High school diploma | 40.4 | 36 | 44.1 | 41 | ||
| Academic | 34.9 | 31 | 25.2 | 23 | ||
| Occupation | Housewife | 92.1 | 82 | 95.6 | 87 | 0.366 |
| Employed | 7.9 | 7 | 4.4% | 4 | ||
| History of abortion | Yes | 21.3 | 19 | 19.8 | 18 | 0.470 |
| No | 78.7 | 70 | 80.2% | 73 | ||
| History of stillbirth | Yes | 3.4 | 3 | 3.3 | 3 | 0.648 |
| No | 96.6 | 86 | 96.7% | 88 | ||
| Fetal macrosomia | Yes | 15.7 | 14 | 8.8 | 8 | 0.116 |
| No | 84.3 | 75 | 91.2% | 83 | ||
| Family history of diabetes | Yes | 53.9 | 48 | 22 | 20 | 0.001 |
| No | 46.1 | 41 | 78.0% | 71 | ||
| History of hypertension | Yes | 13.5 | 12 | 8.8 | 8 | 0.223 |
| No | 86.5 | 77 | 91.2% | 83 | ||
| Prenatal care | Yes | 71.9 | 64 | 78.0% | 71 | 0.121 |
| No | 28.1 | 25 | 22 | 20 | ||
| Pregnancy trimester | 1st | 11.2 | 10 | 7.7 | 7 | 0.067 |
| 2nd | 13.5 | 12 | 8.7 | 8 | ||
| 3rd | 75.3 | 67 | 83.6 | 76 | ||
| BMI (Kg/m2) | < 25 | 11.2 | 10 | 19.8 | 18 | 0.273 |
| 25–29 | 41.6 | 37 | 39.6% | 36 | ||
| ≥ 30 | 47.2 | 42 | 40.7 | 37 | ||
| Frequency of pregnancy | 1 | 30.3 | 27 | 41.8% | 38 | 0.245 |
| 2 | 34.8 | 31 | 30.8 | 28 | ||
| 3 | 22.5 | 20 | 13.2 | 12 | ||
| > 3 | 12.4 | 11 | 14.3% | 13 | ||
* Chi square test
The mean total score of MSPSS was 68.56 ± 7.73 in patients and 65.04 ± 10.81 in controls. The results of independent t-test (Table 2) showed that this difference was statistically significant (p = 0.013). Regarding the MSPSS dimensions, the difference between the two groups was significant in terms of support from family with a mean score of 24.43 ± 2.67 in patients and 23.05 ± 3.02 in controls (p = 0.001) and support from friends with mean score of 19.79 ± 5.51 in patients and 17.12 ± 7.16 in controls (p = 0.006), but not significant in terms of support from significant others (p = 0.325).
Table 2.
Mean scores of MSPSS and BAI in two groups and the results of independent t-test
| Variables | Group | N | Mean ± SD | t | df | Sig.* |
|---|---|---|---|---|---|---|
| Support from family | Patients | 89 | 24.43 ± 2.67 | 3.248 | 178 | 0.001 |
| Controls | 91 | 23.05 ± 3.02 | ||||
| Support from friends | Patients | 89 | 19.79 ± 5.51 | 2.804 | 178 | 0.006 |
| Controls | 91 | 17.12 ± 7.16 | ||||
| Support from significant others | Patients | 89 | 24.32 ± 3.07 | -0.982 | 178 | 0.325 |
| Controls | 91 | 24.86 ± 4.22 | ||||
| Total MSPSS | Patients | 89 | 68.56 ± 7.73 | 2.506 | 178 | 0.013 |
| Controls | 91 | 65.04 ± 10.81 | ||||
| BAI | Patients | 89 | 28.31 ± 5.97 | 2.001 | 178 | 0.047 |
| Controls | 91 | 26.39 ± 6.85 |
The mean score of BAI was 28.31 ± 5.97 in the patient group and 26.39 ± 6.85 in the control group (Table 2). The results of independent t-test showed that this difference was statistically significant (p = 0.047). Pearson correlation test results showed a significant negative relationship between the mean overall score of MSPSS and BAI score in patients (r= -0.329, p = 0.001) and controls (r=-0.204, p = 0.006). This indicates that with the improvement of perceived social support from family and friends, the anxiety of pregnant women with and without gestational diabetes decreases.
In examining the relationship of MSPSS score with demographic and obstetric factors in patients, independent t-test results (Table 3) showed a significant difference in the MSPSS score among patients in terms of having fetal macrosomia (t=-2.890, p = 0.005) and occupation (t=-3.009, p = 0.003) where women with a history of fetal macrosomia and housewives had lower MSPSS scores. No significant difference was found in terms of history of abortion, history of stillbirth, family history of diabetes, history of hypertension, receiving prenatal care, and age (p > 0.05). Furthermore, the results of one-way ANOVA (Table 4) showed that patients with different educational levels (p = 0.001) and frequency of pregnancy (p = 0.010) had significantly different MSPSS scores where those with high school diploma (59.66 ± 12.16) and third pregnancies (59.35 ± 14.20) had lower mean scores. The difference among patients was not significant with respect to BMI, and pregnancy trimester (p > 0.05).
Table 3.
Mean scores of MSPSS in patients with different demographic and obstetric factors and the results of independent t-test
| Factors | Mean ± SD | t | df | P value | |
|---|---|---|---|---|---|
| History of abortion | Yes | 64.26 ± 8.62 | -0.105 | 87 | 0.916 |
| No | 64.58 ± 12.53 | ||||
| History of stillbirth | Yes | 65.66 ± 3.05 | 0.171 | 87 | 0.864 |
| No | 64.47 ± 11.96 | ||||
| History of fetal macrosomia | Yes | 56.50 ± 15.29 | -2.890 | 87 | 0.005 |
| No | 66.01 ± 10.45 | ||||
| Family history of diabetes | Yes | 63.93 ± 12.65 | -0.500 | 87 | 0.618 |
| No | 65.19 ± 10.74 | ||||
| History of hypertension | Yes | 62.50 ± 14.00 | -0.636 | 87 | 0.526 |
| No | 64.83 ± 11.45 | ||||
| Prenatal care | Yes | 64.89 ± 11.74 | 0.477 | 87 | 0.634 |
| No | 63.56 ± 12.02 | ||||
| Age | ≤ 30 | 67.20 ± 9.40 | 1.713 | 87 | 0.090 |
| > 30 | 62.85 ± 12.81 | ||||
| Occupation | Housewife | 63.28 ± 11.56 | -3.009 | 87 | 0.003 |
| Employed | 76.57 ± 4.31 | ||||
Table 4.
Mean scores of MSPSS in patients with different demographic and obstetric factors, and the results of one-way ANOVA
| Factors | Mean ± SD | F | df | P value | |
|---|---|---|---|---|---|
| Pregnancy trimester | 1st | 64.20 ± 9.69 | 0.044 | 2 | 0.957 |
| 2nd | 63.66 ± 9.60 | ||||
| 3rd | 64.71 ± 12.50 | ||||
| Frequency of pregnancy | 1 | 70.29 ± 8.79 | 4.054 | 3 | 0.010 |
| 2 | 63.70 ± 10.52 | ||||
| 3 | 59.35 ± 14.20 | ||||
| > 3 | 62.00 ± 12.23 | ||||
| Education | Lower than high school education | 63.81 ± 11.20 | 8.552 | 2 | 0.001 |
| High school diploma | 59.66 ± 12.16 | ||||
| Academic | 70.64 ± 8.85 | ||||
| BMI (Kg/m2) | < 25 | 66.14 ± 10.71 | 0.107 | 2 | 0.89 |
| 25–29 | 676.10 ± 10.09 | ||||
| ≥ 30 | 66.70 ± 8.64 | ||||
Discussion
The main purpose of this study was to compare the perceived social support of pregnant women (mostly at the third trimester) with gestational diabetes and healthy pregnant women using the MSPSS questionnaire. In overall, results showed a significant difference between the two groups which confirms our first hypothesis. The mean total score of MSPSS was higher in patients (68.56 ± 7.73) compared to controls (65.04 ± 10.81). In Momeni Javid et al.’s study [22] conducted in 2014 on 100 pregnant women with gestational diabetes and 100 healthy controls in Tehran, Iran using the Social Support Questionnaire of Sarason et al. [23], a significant difference was reported between the two groups of pregnant women which is consistent with our results; however, in their study, controls had higher mean MSPSS scores (73.88) compared to patients (65.75). Regarding the components of perceived social support, our results showed that the two groups were significantly different in perceiving support from family and friends, but there was no significant difference in perceiving support from significant others. This indicates the more important role of family and friends in decision making and resilience of diabetic pregnant women which can help reduce stress in pregnant women though emotional support.
Another purpose of our study was to assess the relationship of perceived social support with perceived anxiety in pregnant women with and without gestational diabetes. In this regard, Pearson correlation test results showed a significant negative relationship between the mean overall score of MSPSS and BAI score in patients and controls. This confirms our second hypothesis. In this regard, it can be said that the increase in perceived social support of healthy or diabetic pregnant women can reduce their anxiety. Fayazi et al. [24] used the Depression, Anxiety and Stress Scale (DASS) and Wax’s Social Support Scale and found no significant relationship between social support and anxiety in pregnant women in Zanjan, Iran. Abdollahzade Rafi et al. [25] found no relationship between them among the pregnant women at third trimester in Shiraz, Iran, either. These are against our results. This discrepancy may be due to difference in the assessment tools and the study city. Our study was conducted in Khorramabad city using the MSPSS and BAI tools. Shafaie et al. [26] using DASS and Personal Resource Questionnaire (PRQ), showed a significant negative correlation between perceived social support and anxiety of pregnant women in Tabriz, Iran which is consistent with our results. Neisani Samani et al. [27] in a study on 100 pregnant women under treatment with assisted reproductive technology in Tehran, Iran using BAI and MSPSS, found no significant relationship between anxiety and perceived social support. This discrepancy may be due to difference in geographical location, sample size, or target population.
Finally, our results showed a significant difference in the MSPSS score among pregnant women with gestational diabetes in terms of obstetric factors of “history of fetal macrosomia” and “frequency of pregnancy” as well as demographic factors of “occupation” and “educational level”. Women with a history of fetal macrosomia, housewives, and those with high school diploma had lower MSPSS scores. No significant difference was found in terms of age, BMI, and other obstetric factors of history of abortion, history of stillbirth, family history of diabetes, history of hypertension, receiving prenatal care, and pregnancy trimester. In Abdollahpour et al.’s study [28] on pregnant women in Shahroud, Iran using the Perceived Social Support - Family Scale, a significant relationship was found between mother’s score of family support and her age and education, where mothers with high school diploma and higher education had higher scores. Their results are consistent with our results in terms of education but are against our results with respect to age.
There were some limitations and disadvantages in this study including lack of cooperation of some participants and not assessing the pregnancy outcome due to lack of follow-up phase. Moreover, this study was conducted in one city located in Western Iran. It should be cautious in generalizing the results to all pregnant women in Western Iran. Furthers studies (longitudinal) are recommended on assessing the relationship of perceived social support in diabetic pregnant women with their pregnancy outcome. Furthermore, given that about 47% of pregnant women in our study gained weight, more studies should be conducted to evaluate the relationship between social support and weight gain in pregnant women.
Conclusions
The level of perceived social support is higher in pregnant women with gestational diabetes compared to healthy pregnant women. It has a negative significant correlation with their perceived anxiety. By increasing social support from family and friends, the anxiety of diabetic pregnant women decreases and their pregnancy outcome can be improved.
Acknowledgements
This study was extracted from the professional doctorate thesis of last author. The authors would like to thank all mothers participated in the study.
Funding
No funding was received for conducting this study.
Declarations
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The ethical approval was obtained the Research Ethics Committee of Lorestan University of Medical Sciences (Code: IR.LUMS.REC.1398.216).
Informed consent
Informed consent was obtained from all individual participants included in the study.
Competing interests
The authors declare no conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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