INTRODUCTION:

In today’s world the word ‘stress’ may have a number of meanings. For instance, in Western culture it might mean the loss of emotional control.¹ On the other hand, in Eastern philosophies, stress is considered as the absence of inner peace.¹ In Psychological terms, Richard Lazarus defined stress as a state of anxiety produced when events and responsibilities exceed one’s coping abilities.¹ On Physiological basis, according to Selye, stress may be defined as the non specific response of the body to any demand placed upon it to adapt, whether that demand produces pleasure or pain. In the field of holistic medicine, stress is defined as the inability to cope with a perceived (real or imagined) threat to one’s mental, physical, emotional and spiritual well-being, which results in a series of physiological responses and adaptations.¹

Pregnancy is a special and joyful period for a woman, which brings in a lot of changes in her life and gifts her with the joy of motherhood. Pregnancy is a period of a mature crisis with significant potential for positive development.² The mother-to-be embraces a lot of new responsibilities of the unborn child and this brings a lot of biopsychosocial changes in her own life. Every pregnant woman experiences some stress of some sorts, it may be financial crisis or just how to assemble the crib correctly.³ The psychosocial stress in pregnancy, defined as “the imbalance that a pregnant woman feel when she cannot cope with demands... which is expressed both behaviourally and physiologically”⁴, has not routinely been measured in everyday obstetric practice.

One of the studies shows that, 70% of the primi antenatal mothers experience mild stress and 30% experience moderate stress.⁵

The aim of this review was to have an understanding regarding stress and its short-term as well as long-term impact on pregnant women and her unborn child. The objectives of the review were to get an overview on maternal stress and to understand its effect on pregnant women as well as her foetus.

METHOD:

The electronic literature search engines used were Google scholar and PubMed for selecting papers related to the theme stress and pregnancy. The articles selected were in English language only and Again these selected articles were further screened for more relevant literature. For the present paper, a total of 20 articles were reviewed which were published online. Cross-sectional, evaluative and longitudinal cohort studies were a part of this review article.

RESULTS:

Factors affecting antenatal stress:

The pregnant women may face a certain level of stress during pregnancy because of the new role endorsed upon her, her own health as well as the child-to-be born becomes her responsibility. Hormonal changes occurring during pregnancy causes profound physical and physiological transformations. These changes are the adaptations that are helpful in the better accommodation of the foetus, its proper growth and in receiving proper nutrition. But these changes can sometimes cause discomfort and may cause stress for the pregnant women.⁶ Social support is one of the crucial aspects during pregnancy, and rate of stress in mothers with less social support was significantly more than others.⁷Domestic violence, drug use and having co-morbidities were significantly associated with high psychosocial stress during pregnancy.⁸In another study, no significant relationships were found between socio-economic status and perceived stress of pregnant women.⁹

Stress was found to be related to women staying in nuclear family (p<0.05).¹⁰ In another study gravidity, educational status and monthly family income was found to be significantly associated with antenatal stress.¹¹ Educational status of the mother as well as that of husband were not found to be having any significant influence in causing stress.¹²Again primi mothers were found to be more in the stress group (43%) and the relation was also found statistically significant.¹²

The psychosocial stressors identified in infertile women between both the groups showed significant association related to contraceptives and abortion.¹³ This may be understood under the light of Indian social belief that women are completely responsible for pregnancy.

Again the antenatal mothers having inadequate knowledge and belief regarding antenatal care may contribute to stress. In a study it was found that antenatal mothers had much knowledge in areas of antenatal check-up, diet, activity and rest while they had least knowledge regarding travelling, coitus, hygiene and danger signs during pregnancy.¹⁴

Maternal outcomes:

Hypertension during pregnancy is a serious health condition and it contributes to a number of maternal and perinatal morbidity and mortality. Pre-eclampsia is a multi-system disorder of unknown aetiology characterised by development of hypertension to the extent of 140/90mm of Hg or more with proteinuria after the 20^th weeks in a previously normotensive and non-proteinuric woman.¹⁵ Very few studies have focussed on finding out the relation between psychosocial factors and pre-eclampsia. The women who were residing in a high stress environment displayed significantly higher systolic and diastolic blood pressure, both during the relatively calm period and during a war, than women living in the low stress environment.¹⁶ However, in another study, no significant differences were found between women with low and high stress scores with regard to pre-eclampsia during pregnancy, nor there was any pressure changes during pregnancy found between the groups.¹⁷

The results of the researches done on relation between maternal exposure to stressful events and preterm labour were pretty consistent and on their basis it may be concluded that preterm deliveries are often preceded by stressful situations. A study conducted by Dole et al¹⁸ found out that maternal perception of the negative life events between 24 and 29 weeks gestation was significantly related to increased risk of preterm birth. The risk of preterm birth was associated with measures of perceived difficulties at 20 and 30 weeks gestation, the association was strongest with 20 weeks, however, the risk was independent of smoking.¹⁹

Intra-partum complications:

A lot of studies have been conducted for finding out the nature and severity of intra-partum complications and the relationship between various psychosocial factors and their occurrences. The outcome variables of these researches were prolonged labour, umbilical cord around the neck, cleft palate and still birth. In one of the study it was found that tension was unrelated to length of first labour phase and delivery complications; tension was positively related to weight gain and length of second phase of labour.²⁰ Beck et al²¹found out that anxiety during pregnancy was not associated with any maternal complications; however state anxiety at the time of admission was predictive of length of labour.

Neonatal outcomes:

Many of the researchers have investigated on the impacts of maternal stress on unborn child. In this regard, there was link found between prenatal stress and pregnancy outcomes in humans. However, the relation between prenatal stress and neonatal outcomes appears to depend, in part, upon the nature of stressful experience as well as the specific outcome under investigation.²²

Again it was also observed in few of the studies that increased maternal stress was associated with still birth²³, low birth weight^24,25 and preterm delivery²⁶.

Still birth is the birth of a newborn after 28^th completed week (weighing 1000 gm or more) when the baby does not breathe or show any sign of life after delivery.¹⁵ Wisborg et al²³found out in their study that antenatal women with high level of psychological stress during pregnancy had 80% increased risk of still birth.

Low birth weight (LBW) infant is defined as one whose birth weight is less than 2500 gm irrespective of the gestational age.¹⁵This may result from various reasons including preterm delivery, intrauterine growth retardation or a combination of both the conditions. LBW is associated with previous preterm delivery, low social support and smoking.²⁴ In another study, no relation was found between stressors and birth weight.²⁵

Preterm birth (PTB) is defined as one when birth occurs before completion of 37 menstrual weeks of gestation regardless of birth weight.¹⁵Nkansah-Amankra et al²⁶found out that maternal stress was significantly associated with increased risk of preterm delivery.

Infant and childhood outcomes:

Several prospective studies suggest that antenatal stress is associated with adverse neuro-behavioural outcomes, including social/emotional and cognitive functioning during childhood. Although different methods were used for measuring antenatal stress and postnatal outcome, then also the results were consistent across all the studies in view of the prospective association between antenatal stress and neuro-behavioural development.

The most consistently measured adverse effect of maternal stress was attention deficit hyperactivity disorder (ADHD) symptoms in various researches.^{27, 28}

DISCUSSION:

The review has confirmed that pregnant women go through stress during pregnancy and it has short term as well as long tern effect on the physical and mental wellbeing of the mother-to-be and the foetus.

The researches done to find out the association between maternal stress during pregnancy and birth weight outcome, the differences found in the results can be attributed to the inclusion of both nulliparous and multiparous women and use of different measuring tools for stress level.

The opposite conclusions found in the results of the researches done on pre-eclampsia, may be due to the different operationalization techniques. In some of these studies researchers measured life events during pregnancy in a retrospective design, while others measured it in a prospective design.

The researches done on the relation between intra-partum complications and maternal stress and anxiety comes to no definitive conclusions. However, the ‘trait anxiety’ of the pregnant women was found to be positively related with ‘abnormal delivery’, particularly prolonged labour. This might be due to the inadequate operationalization of the term ‘intra-partum complication’ in these researches.

IMPLICATION AND FUTURE RESEARCH:

The understanding that stress is an unique and individual process and that its proper knowledge will enable the health professionals in giving the individualized needed care to them. Early recognition of maternal stress and its prompt treatment or intervention has the potential for prevention of many neuro-developmental problems in the neonates of these mothers.

There are very limited studies done on the improving well-being of the pregnant women. Therefore, future researchers may take up studies developing on intervention modules for enhancing the well-being and reducing the stress among antenatal mothers.

LIMITATION:

The review was limited to only those research articles which were published online in English language. Further, the researcher had utilized only two databases to obtain the research articles.

CONCLUSION:

In this review, it was attempted to find out how the various factors directly or indirectly influence the pregnancy outcome. Although most of the studies don’t come together to a definitive answer and rather gives an ambiguous conclusion. There should be better common understanding of the concepts measured perinatally. This further necessitates more researches in the area of stress during pregnancy.

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Received on 27.09.2021 Modified on 04.04.2022

Asian J. Nursing Education and Research. 2022; 12(3):279-282.

DOI: 10.52711/2349-2996.2022.00059