International Journal of Africa Nursing Sciences 3 (2015) 1–7

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Prevalence of pregnancy anxiety and associated factors

Girija Kalayil Madhavanprabhakaran a,⇑, Melba Sheila D’Souza b, Karkada Subrahmanya Nairy c
a
Maternal and Child Health Nursing, College of Nursing, Sultan Qaboos University, P.O. Box 66, Alkhod, Muscat, Oman
b
Adult Health and Critical Care, College of Nursing, Sultan Qaboos University, Oman
c
Department of Business Studies, Higher College of Technology, Al Khuwair, Muscat, Oman

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the prevalence of pregnancy-specific anxiety (PSA) and its associated factors
Received 7 December 2014 among pregnant women during the three trimesters of pregnancy.
Received in revised form 8 May 2015 Design: A prospective explorative survey was conducted among 500 low-risk Indian pregnant women of
Accepted 26 June 2015
age 18–35 years.
Available online 3 July 2015
Setting: A major maternity government hospital in southern state of Kerala, India.
Participants: 500 low risk pregnant women who attended the major maternity government hospital dur-
Keywords:
ing the period June 2004–July 2005 were selected as convenient sample.
Pregnancy-specific anxiety
Childbirth anxiety
Methods: An exploratory research design with a prospective cohort approach was adopted for the study.
Fear of childbirth State Trait Anxiety Inventory (STAI) and Pregnancy-Specific Anxiety Inventory (PSAI) were used to collect
Pregnancy anxiety the data.
Nulliparous women Results: Highest prevalence of pregnancy-specific anxiety (PSA) was reported during the third trimester
of pregnancy. All pregnant women rated high levels of third trimester childbirth anxiety compared to
other three components of pregnancy-specific anxiety. Nulliparous pregnant women reported higher
levels of PSA than parous pregnant women (M = 134.40, M = 116.8). Young age, nulliparous status and
nuclear family nature were identified as common risk factors of pregnancy-specific anxiety.
Conclusion: During the transition to motherhood, the risk factors and timing of heightened
pregnancy-specific anxiety differ. Higher prevalence of pregnancy anxiety among nulliparous and
younger pregnant women necessitates an integrated routine screening of PSA during prenatal care.
Early detection, prevention and management of pregnancy anxiety will enable women to cope with
the challenges of pregnancy.
Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Teixeira, Figueiredo, Conde, Pacheco, and Costa (2009) revealed a

Pregnancy is not only a period of great joy, but also one of great
stress to a woman both physically and mentally. Even in healthy
women, pregnancy may give rise to many anxieties because of
anticipated uncertainty associated with it. Evidences show that
pregnancy anxiety not only affects pregnant women’s health but
also have an impact on labour outcomes such as preterm delivery,
prolonged labour, caesarean birth, low birth weight (Catov,
Abatemarco, Markovic, & Roberts, 2010; Hernandez-Martinez,
Val, Murphy, Busquets, & Sans, 2011; Lobel et al., 2008;
Rauchfuss & Maier, 2011). Findings of Lee et al. (2007) and
⇑ Corresponding author. Tel.: +968 2414(5411), GSM: +968 92797342 (O); fax:
+968 2441 3536.
E-mail addresses: girija@squ.edu.om, km_girija@yahoo.com (G.K. Madhavan-
prabhakaran), melba123@rediffmail.com (M.S. D’Souza), ksnairy@gmail.com (K.S.
Nairy).
varied prevalence of pregnancy anxiety at different trimesters of
pregnancy with high levels in first and third trimesters.
Previous studies on pregnancy anxiety from different part of the
world reported a high and diverse prevalence rate of 14–54%.
However, most of these studies explored general pregnancy anxi-
ety than pregnancy-specific anxiety (García Rico, Rodríguez, Díez,
& Real, 2010; Hernandez-Martinez et al., 2011; Nieminen,
Stephansson, & Ryding, 2009; Teixeira et al., 2009).
Pregnancy-specific anxiety is defined as worries, concerns and
fears about pregnancy, childbirth, and health of infant and future
parenting (Huizink, Mulder, Robles de Medina, Visser, &
Buitelaar, 2004). Serçekusß and Okumusß (2009) reported that nulli-
parous women’s childbirth fears were related to labour pain,
birth-related problems and procedures.
Previous researches on pregnancy anxiety concluded that
pregnancy-specific anxieties are the real predictors of adverse
labour outcomes than general anxiety. These researchers

http://dx.doi.org/10.1016/j.ijans.2015.06.002
2214-1391/Ó 2015 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 G.K. Madhavanprabhakaran et al. / International Journal of Africa Nursing Sciences 3 (2015) 1–7
recommended that estimation of pregnancy-specific anxiety bene-
fit in identification and risk reduction more specifically
(Bayrampour, Heaman, Duncan, & Tough, 2013; Huizink et al.,
2004; Rauchfuss & Maier, 2011; Reck et al., 2013). With limited
evidences available on specific fears and worries related to preg-
nancy, the structure of pregnancy anxiety and its impact on preg-
nancy outcomes necessitate further studies exploring
pregnancy-specific anxieties and its risk factors.
The formal childbirth education classes are not generally avail-
able in various hospitals in Kerala, India and even the measures to
explore anxiety during pregnancy are buried under heavy patient
loads. High prevalence (90–94%) of childbirth anxiety and poor
knowledge on preparation for childbirth among nulliparous preg-
nant women of Kerala were reported by previous studies on nulli-
parous pregnant women (Lucy Joseph, 2010; Mary, 2006). Proper
addressing of pregnancy anxiety becomes difficult due to the
non-availability of formal childbirth education classes. The tradi-
tional way of transferring knowledge on pregnancy and childrear-
ing from mothers to daughters is vanishing due to the urbanisation
and the trend toward nuclear family system. To the best of our
knowledge, the pregnancy-specific anxiety has not been investi-
gated well in the current setting.
The significance of estimation of pregnancy-specific anxiety and
its associated factors towards specific risk reduction demand for
comprehensive research on pregnancy-specific anxiety. This study
was aimed at determining the levels of pregnancy-specific anxiety
and its associated risk factors, which in turn would help in design-
ing and implementing appropriate strategies intended for reduc-
tions of adverse pregnancy outcomes. Objectives of the study
were to determine the prevalence of pregnancy-specific anxiety
during the three trimesters of pregnancy and to identify the asso-
ciated risk factors.
2. Literature review
Pregnancy anxiety varies from woman to woman. The level of
stress pregnant women experiences affects the outcome of preg-
nancy. An observational, analytical cross-sectional study among
174 third trimester pregnant women in Spain revealed that preg-
nant women’s anxiety levels were higher than average levels in
the general population (García Rico et al., 2010). High prevalence
of antenatal anxiety-both State and Trait anxiety-was reported
from 453 pregnant women in Sao Paulo (Faisal-Cury & Rossi
Menezes, 2007).
A prospective study among 160 third trimester Iranian pregnant
women, showed a significant relationship between general anxiety
and fear of childbirth. Nulliparous women reported higher levels of
anxiety in 28thand 38th weeks of gestation than parous (Alipour,
Lamyian, & Hajizadeh, 2012). Study among 660 low risk third tri-
mester Turkish pregnant women revealed a significant relationship
between fear of childbirth and general anxiety and higher scores of
fear of childbirth in nulliparous women than parous women
(Körükcü, Fırat, & Kukulu, 2010). An observational cross-sectional
study in Northern Ireland among 263 healthy low-risk mothers
found that there was a high degree of pregnancy-related anxiety
among nulliparous pregnant women (Lynn, Alderdice, Crealey, &
McElnay, 2011).
A cross-sectional descriptive survey conducted among 650 low
risk third trimester pregnant women of 17–46 years of age
revealed 25% childbirth fear and the authors concluded that the
risk factors and timing of heightened anxiety during the transition
to motherhood differ in pregnant women (Hall, Stoll, Hutton, &
Brown, 2012). Henderson and Maggie (2013) reported 14% preva-
lence of antenatal anxiety from 5332 samples of maternity clinic
attendance of England. They identified young maternal age as well
as ethnicity as risk factors of pregnancy anxiety. A
population-based community study among 916 Swedish first tri-
mester women by Rubertsson, Hellstrom, Cross, and Sydsjo
(2014) estimated 15.6% prevalence of anxiety symptoms and
reported that women under 25 years of age were at an increased
risk of anxiety symptoms. They concluded that anxiety symptoms
during pregnancy increased the rate of preference for caesarean
section. Arch (2013) investigated socio-demographics of pregnant
women to find out predictors of pregnancy anxiety in US sample
of 311 pregnant women. They concluded that younger age, nulli-
parous status and high levels of general and state anxiety predicted
higher pregnancy-related anxiety.
Many studies reported that the high preference for caesarean
section was associated with fear of childbirth. Fenwick, Gamble,
Nathan, Bayes, and Hauck (2009) reported that nulliparous women
experienced more childbirth fear and the high antenatal fear was
associated with emergency caesarean delivery. An Israeli study
investigated the psychological traits as well as social and demo-
graphic factors associated with caesarean section on maternal
demand among 59 healthy primigravid women. The study con-
cluded that fear of childbirth was the only psychological variable
associated with the choice for caesarean section. (Handelzalts
et al., 2012).
Nieminen et al. (2009) reported that maternal request for cae-
sarean section was out of fear of intense childbirth. In a Danish
National Birth Cohort with nulliparous women found that fear of
childbirth in early (16 weeks) and late (31 weeks) pregnancy was
associated with emergency caesarean section (Laursen, Johansen,
& Hedegaard, 2009). Despite the fact that extensive measures are
observed to decrease the rate of caesarean sections, the trend of
caesarean births is increasing considerably even in many devel-
oped countries (Fenwick et al., 2009). One possible contributor to
this upward trend of caesarean is the maternal demand due to high
childbirth anxiety.
The results from a large- multi ethnic community-based study
in Amsterdam involving 7740 pregnant women revealed that preg-
nancy anxiety was related with adverse labour outcomes such as
preterm and low birth weight (Loomans, van Dijk, et al., 2013).
Catov et al. (2010) conducted a prospective longitudinal study
among 667 African American pregnant women revealed that
maternal anxiety was associated with increased risk of preterm
birth and low birth weight. Rauchfuss and Maier (2011) concluded
from their prospective study among 580 German pregnant women
that pregnancy related anxiety was positively linked to preterm
delivery. An explorative study among Spanish 205 pregnant
women and reported that maternal anxiety were related to less
gestational age at birth, mode of delivery and infant birth weight
(Hernandez-Martinez et al., 2011).
Assessment of general anxiety during pregnancy may underes-
timate pregnancy-specific anxiety. The structure of pregnancy-
specific anxiety was explored among 230 normal risk nulliparous
pregnant women using a 34-item pregnancy-related anxiety ques-
tionnaire. They reported marked increase in pregnancy-specific
anxiety and suggested measurement of pregnancy-specific anxiety
to address issues of prediction, identification and risk reduction
more precisely and effectively (Huizink et al., 2004). German sam-
ple of 88 women was examined to determine whether anxiety
symptoms during pregnancy had an impact on the duration and
method of childbirth using and STAI and pregnancy-specific anxi-
ety questionnaire. They reported that childbirth-specific anxiety
assessed by the revised pregnancy-specific anxiety questionnaire
was an important predictor of total birth duration whereas; gen-
eral anxiety measured by the STAI had no effect (Reck et al.,
2013). Bayrampour et al. (2013) concluded that pregnancy related
anxiety as risk predictor of pregnancy risk among nulliparous
women. Even though the exploration of pregnancy-specific anxiety
 G.K. Madhavanprabhakaran et al. / International Journal of Africa Nursing Sciences 3 (2015) 1–7
and its associated risk factors would help to develop and imple-
ment specific interventions which would eventually reduce the
adverse labour outcomes, only few studies are confined to mea-
surement of pregnancy-specific anxiety. The present study deter-
mined the prevalence of pregnancy-specific anxiety levels during
the three trimesters of pregnancy and its associated risk factors
in Kerala, India.
3. Methods
An exploratory research design with a prospective cohort
approach was adopted for the study. All pregnant women attend-
ing antenatal clinic of the setting were considered as population.
Pregnant women who met the inclusion criteria and volunteered
to participate in the study were recruited to the study as conve-
nient samples. The study was conducted among 500 low risk preg-
nant women attending one of the major government hospitals in
southern state of Kerala, India during the period from June 2004
– July 2005. Only willing women in the age group of 18–35 years
with low risk pregnancy and singleton foetus expecting normal
delivery were selected for the study provided they were educated,
having sound mental and physical health. All pregnant women
with moderate and high risk pregnancy were excluded.
3.1. Description of the tools and reliability
General anxiety was measured by a standardised tool State Trait
Anxiety Inventory (STAI) (Spielberger, 1989), a self-report 40 item
Likert scale with total score of 160 and is widely used in pregnancy
(Faisal-Cury & Rossi Menezes, 2007). Both state and trait anxiety
were measured and analysed separately. Internal consistency
ranges from 0.86 to 0.85 for state and 0.89 to 0.91 for trait subscale.
Cronbach’s alpha was 0.88 for state and 0.83 for trait anxieties,
reflecting the tool reliability.
Pregnancy-specific anxiety was assessed by a standardised
structured Pregnancy-Specific Anxiety Inventory (PSAI), 40 items
self-report questionnaire on a five-point Likert scale with a maxi-
mum score of 200. It measured the intensity of woman’s pregnancy
anxiety related to four areas of pregnancy and childbirth. Anxiety
about Being Pregnant (ABP) with 16 items; Anxiety of Childbirth
(ACB) with 10 items; Anxiety about Breastfeeding (ABF) with eight
items and Anxiety about New born Care (ANB) with questions
items were parts of the PSAI. The face and content validity of the
PSAI were established by expert review and pilot study. The relia-
bility coefficient of 0.76 assured the reliability of PSAI.
Socio-personal and obstetric variables were collected during the
initial interview. The items included were pregnant women’s age,
obstetric scores such as gravidity; history of abortions; stillbirth;
the weeks of gestation; education and occupation of the pregnant
woman and husband; the type of family; support systems, family
history of mental illness; sources of information for pregnant
women and husband’s habit of smoking, drinking and alcoholism.
In addition, the satisfaction and quality of marital life and relation-
ship with in-laws were also explored on a five- point rating scale.
3.2. Ethical consideration
The study was conducted after the approval of Ethical Advisory
Committee of the Schools of Behavioural Sciences under Mahatma
Gandhi University. Permission for data collection was obtained
from the District Medical Officer. An informed written signed con-
sent was obtained from each participant, which emphasised volun-
tary nature, anonymity and the right to withdraw from the study at
any point without affecting their routine care. The data were kept
locked and confidential.
3
3.3. Data collection procedure
The pregnant women who met the inclusion criteria were
recruited to the study during their first trimester period. An aver-
age antenatal attendance of 60–75 pregnant women per day
assured feasibility for adequate sampling from June 2004 – July
2005. A convenient sampling method was used depending upon
eligibility and voluntary willingness from those who attended
antenatal clinic. Each informed and signed first trimester pregnant
woman was contacted by the researcher and interviewed for
socio-personal variables in a convenient room next to antenatal
clinic. Then they were asked to self-rate their anxiety level using
STAI and PSAI. Participants were asked to read through each state-
ment in the PSAI and STAI carefully and then mark their perceived
levels of anxiety on a 1–5 rating scale against each statement. Each
rating score meaning was explained and reinforced to them. The
average time taken by each participant at initial contact was 15–
20 min. These selected women were followed up in the second
and third trimesters during their regular antenatal visits to the
clinic and the subsequent data on anxiety levels were collected
by a trained research assistant using the same tools.
The data were analysed using SPSS version 16 with two-tailed
significance level of less than 0.05. Frequency and percentage were
calculated to determine the prevalence of anxiety. General Linear
Model (GLM)-Repeated Measures test were used to study variations
in anxiety along pregnancy period and tested levels of significance
among inter-trimester anxiety scores. GLM- Repeated Measures
model is used to model dependent variables measured at multiple
times. GLM-Repeated Measures model can test the main effect on
repeated measures between subject’s factors, main effects of within
subject’s factors like measurement times, interaction effects
between factors, covariates effects, and also effects of interaction
between covariate and between-subjects factors (Stevens, 2009).
4. Results
4.1. Socio-personal characteristics
Majority (69%) of the pregnant women were nulliparous. More
than half (60%) of them were in the age group 20–24 years. Most
(93%) of the women had high school education and above, of which
7.4% had post-graduation and 2% were professionals. Majorities
(81.6%) were housewives and 80% belonged to nuclear families.
Only 9.6% of the women had a history of abortion due to unknown
reasons. Almost all (96%) of them reported having good support
system and satisfied marital life (88%). There was no reported fam-
ily history of mental illness or drug addiction. Forty-three percent-
ages of women had spouse with smoking habit and 12.2% had
spouse who consumed alcohol.
4.2. General anxiety during trimesters of pregnancy
All women had moderate (71%) to severe (29%) degree anxiety
levels during third trimester. During first trimester also almost
all women reported moderate (48.6%) to severe (48.4%) degree
general anxiety compared to second trimester. Table 1 reveals that
the mean third trimester anxiety score was the highest (106.89)
compared to first and second trimesters respectively (100.36,
85.50). The GLM test for these inter-trimester variations were sig-
nificant (F = 369.726, P < 0.001).
4.3. Pregnancy-specific anxiety (PSA) during trimesters of pregnancy
High prevalence of moderate levels of PSA was reported in all
trimesters. As shown in Fig. 1 the highest prevalence of (22%)
4 G.K. Madhavanprabhakaran et al. / International Journal of Africa Nursing Sciences 3 (2015) 1–7

Table 1 Table 2
Prevalence and Level of Significance of General Anxiety (STAI) across Trimesters of Mean standard deviation and level of significance of pregnancy-specific anxiety (PSA)
Pregnancy. across trimesters of pregnancy.

STAI Mild Moderate Severe Mean SD GLM test and P Pregnancy-specific anxiety (PSA) Mean SD GLM test and P value
scores % % % value
PSA-1 (Trimester-1) 118.77 11.633 F = 621.225
STAI-1 3.0 48.6 48.4 100.36 13.637 F = 369.72 PSA-2 (Trimester-2) 106.06 10.691 P < 0.001
STAI-2 28.2 60.6 11.2 85.50 12.933 P < 0.001 PSA-3 (Trimester-3) 126.90 11.861
STAI-3 – 71.0 29.0 106.89 10.952

STAI-1, 2, 3: State Trait anxiety inventory at trimester one two three respectively.
Table 3
Prevalence and level of significance of anxiety of being pregnant (ABP) across
trimesters of pregnancy.
severe degree of PSA was reported during third trimester. Almost
all (99%) women at third trimester had moderate to severe degree ABP Mild Moderate Severe Mean SD GLM test and P
of PSA as evidenced by the highest mean scores (126.90) of PSA in scores % % % value
Table 2. The inter-trimester differences of means were statistically ABP-1 1.6 69.0 29.4 52.01 6.232 F = 578.048
tested using GLM test. The value of F (621.225) shows that the PSA ABP-2 11.8 87.8 0.4 45.26 5.066 P < 0.001
across the three trimesters differed significantly at 0.01 levels. ABP-3 1 61 38 53.94 5.886

ABP-1, 2, 3: Anxiety of Being Pregnant during first, second and third trimesters.
4.4. Section-wise results of pregnancy-specific anxiety

Four areas of pregnancy-specific anxiety (PSA) such as anxiety 100%

of being pregnant (ABP), anxiety about childbirth (ACB), Anxiety
90% 25%
about Breast Feeding (ABF) and Anxiety about New born Care
(ANB) were analysed separately. 80% 42.40%
70% Severe
Percentage

4.4.1. Anxiety of being pregnant (ABP) 60% Moderate

Table 3 reveals that most (69%) of the pregnant women had 93% Mild
moderate ABP during the first trimester. Across the trimesters 50%
the highest prevalence of 38% severe ABP was reported during 40% 70.40%
third trimester. Inter-trimester differences in the anxiety of being 30% 57.60%
pregnant were tested statistically using GLM test. The value of F
20%
(578.048) shows that in each trimester anxiety of being pregnant
differed significantly at 0.01 levels. 10% 6%
4.60% 1%
0%
4.4.2. Anxiety about childbirth (ACB) Trimester-1 Trimester-1I Trimester-1II
Fig. 2 reveals highest prevalence of 93% severe childbirth anxi-
Fig. 2. Prevalence of anxiety about childbirth (ACB) across the three trimesters of
ety during third trimester. During first trimester 42.4% pregnant pregnancy.
women also reported severe childbirth anxiety. The mean scores
were also varied with high mean score of 38.70 in third trimesters
(Table 4). Inter-trimester variations were significant at 0.001 levels trimester women rated the highest levels of severe degree of ABF.
as revealed in Table 4. GLM test revealed that inter trimester variations were significant
(F = 35.679, P < 0.001).
4.4.3. Anxiety about breastfeeding (ABF)
Prevalence of 42.2% and 36.2% moderate level of ABF were 4.4.4. Anxiety about new born care (ANB)
reported during third and first trimester respectively. During third The highest prevalence of (51.4%) moderate and 5.6% of severe
ANB were reported during third trimester. GLM test revealed that
inter trimester variations were significant (F = 51.254, P < 0.001).
0.40%
100.0%
8.4%
22%
4.5. Socio-demographic variables and PSA

80.0% All the socio-demographic variables showed significant associa-

tion at 0.05 levels at third trimester PSA. A consistent significance
74% Severe between parity and PSA was noted in all trimesters. Among all
Percentage

60.0%
Moderate socio-personal variables; younger age, parity and type of family
89.2% Mild were associated with third trimester pregnancy-specific anxiety.
40.0% 77%

Table 4
The Mean, SD and level of significance of anxiety about childbirth (ACB) across
20.0%
trimesters of pregnancy.
25.6%
Anxiety about childbirth (ACB) Mean SD GLM test and P value
2.4% 1%
0.0% ACB-1 35.09 2.969 F = 432.689
Trimester-1 Trimester-II Trimester-III ACB-2 31.94 4.232 P < 0.001
ACB-3 38.70 3.194
Fig. 1. Prevalence of pregnancy specific anxiety (PSA) across the three trimesters of
pregnancy. ACB-1, 2, 3: Anxiety about Childbirth during first, second and third trimester.
 G.K. Madhavanprabhakaran et al. / International Journal of Africa Nursing Sciences 3 (2015) 1–7 5

Younger age group of18–20 rated high anxiety compared to older Table 6
groups. Those who belonged to nuclear families reported more The Mean, SD and level of significance of mean scores of each section of PSAI –
nulliparous and parous pregnant women using GLM-test.
PSA and these scores were significant at 0.05 levels.
Both multiparous and nulliparous mothers reported high third Anxiety Nulliparous Parous pregnant Level of Significance
trimester PSA compared to other trimesters. Nulliparous pregnant pregnant women (N -156)
women (N-346)
women (Table 5) reported higher PSA across all trimesters with
highest during third trimester PSA (mean 131.40) compared to par- Mean SD Mean SD

ous women (mean 116.80). The same pattern was observed along ABP-1 54.11 5.555 47.31 4.993 F = 578.05
the four component of PSA (Table 6) with highest childbirth anxi- ABP-2 45.96 5.180 43.69 4.429 P < 0.05
ABP-3 55.57 5.699 50.26 4.484
ety among the nulliparous (mean 39.26).
GLM test revealed significant at 0.05 levels for score differences ACB-1 35.67 3.047 33.78 2.310 F = 432.69
ACB-2 31.98 4.267 31.86 4.167 P < 0.05
among nulliparous and parous pregnant women. This indicates
ACB-3 39.26 3.200 37.44 2.810
that pregnancy-specific anxiety is higher among nulliparous
ABF-1 19.68 4.393 15.62 2.677 F = 35.679
women.
ABF-2 17.14 3.414 14.62 2.829 P < 0.05
ABF-3 20.28 3.807 16.29 3.104
5. Discussion ANB-1 14.21 3.346 10.92 2.089 F = 51.254
ANB-2 12.96 3.453 11.60 2.985 P < 0.05
This study revealed a varied and high prevalence rate of moder- ANB-3 16.18 3.417 12.71 2.644

ate to severe degree of general anxiety (STAI) during the first and
third trimester. Previous studies (Faisal-Cury & Rossi Menezes,
2007; García Rico et al., 2010) also reported high STAI score among
pregnant women. It has been reported that women with a high
general anxiety tend to have more pregnancy-specific anxiety
(Alipour et al., 2012; Arch, 2013; Hall et al., 2012).
5.1. Pregnancy-specific anxiety (PSA)
The highest prevalence of pregnancy-specific anxiety was
reported during the third trimester. Throughout the course of preg-
nancy, high levels of PSA were observed in first and third trimester
with low prevalence in second trimester contributing to a U pat-
tern. The current finding is consistent with similar finding of U pat-
tern of anxiety in other studies (Lee et al., 2007; Teixeira et al.,
2009). Previous studies on pregnancy related anxiety among low
risk pregnant women also reported marked increase of PSA in third
trimester (Alipour et al., 2012; Hall et al., 2012; Huizink et al.,
2004; Körükcü et al., 2010; Laursen et al., 2009; Lynn et al.,
2011; Reck et al., 2013).
ABP-1, 2, 3: Anxiety of Being Pregnant during first, second and third trimesters.
ACB-1, 2, 3: Anxiety about Childbirth during first, second and third trimesters.
ABF-1, 2, 3: Anxiety about Breastfeeding during first, second and third trimesters.
ANB-1, 2, 3: Anxiety about New born Care during first, second and third trimesters.
given to decrease the childbirth anxiety due to its impact on abnor-
mal pregnancy outcomes mainly of cesarean sections. Previous
studies supports this suggestion as their studies also revealed that
request for caesarean sections were higher among pregnant
women particularly nulliparous with more childbirth fears
(Fenwick et al., 2009; Hall et al., 2012; Handelzalts et al., 2012;
Laursen et al., 2009; Nieminen et al., 2009; Rubertsson et al.,
2014). Evidences also established the relationship between high
levels of pregnancy anxiety and adverse labour outcomes such as
preterm births, low birth weight and mode of delivery (Catov et
al., 2010; Hernandez-Martinez et al., 2011; Loomans et al., 2013;
Rauchfuss & Maier, 2011). So current study recommend that the
prenatal care should focus on measures to reduce pregnancy speci-
fic anxiety particularly among nulliparous women which would
reduce adverse pregnancy outcomes.

5.2. Childbirth Anxiety

5.3. Association of PSA with socio- personal variables
The current study reported very high prevalence of severe
The study revealed that nulliparous status is an influencing fac-
degree of third trimester childbirth anxiety. Nulliparous women
tor for high prevalence of PSA. These findings are consistent with
reported higher childbirth anxiety than parous mothers; these
previous studies (Alipour et al., 2012; Arch, 2013; Fenwick et al.,
results are consistent with similar previous studies (Alipour
2009; Handelzalts et al., 2012; Huizink et al., 2004; Körükcü
et al., 2012; Hall et al., 2012; Huizink et al., 2004; Körükcü et al.,
et al., 2010; Lynn et al., 2011; Teixeira et al., 2009). Evidences show
2010; Laursen et al., 2009; Lynn et al., 2011). Portuguese nulli-
that lack of support and poor marital relationship, dissatisfaction
parous women had reported high third trimester childbirth anxiety
with family members and less social supports as the predictors
(Figueiredo & Conde, 2011).
of anxiety in pregnancy and postpartum period (Karacam &
The present study revealed high prevalence of pregnancy speci-
Ancel, 2009; Rubertsson et al., 2014). But, these studies contradict
fic anxiety especially childbirth anxiety component among nulli-
with the present study findings of strong family support, satisfied
parous women. This finding urges that special attention to be
marital relationship and good family relationship as predictors.
The younger women experienced more pregnancy anxiety
Table 5 which is comparable with reported studies (Arch, 2013;
The Mean, SD and level of significance of mean scores of Pregnancy-Specific Anxiety Henderson & Maggie, 2013; Rubertsson et al., 2014).
Inventory (PSAI) With nulliparous and parous pregnant women. The nuclear family nature prompted to reduce exposure to tra-
Anxiety Nulliparous Parous pregnant GLM-test ditional knowledge transfer from mother to daughter compared to
pregnant women women (N-156) previous extended family system. The lack of scientific and com-
(N-346) prehensive information on childbirth preparation contributed to
Mean SD Mean SD increased worries related to pregnancy. Though these educated
PSAI-1 123.65 10.158 107.81 5.83 F = 252.03 women look for available in formations through magazines, media
PSAI-2 107.95 10.882 101.81 8.92 P < 0.05 and friends which were neither comprehensive nor complete,
PSAI-3 131.40 10.693 116.80 7.25 rather it triggered their increased pregnancy-specific anxiety. The
PSAI-1, 2, 3: Pregnancy-Specific Anxiety Inventory during first, second and third public hospitals in Kerala neither have a formal childbirth prepara-
trimester. tion classes nor a comprehensive hand-out on childbirth
6 G.K. Madhavanprabhakaran et al. / International Journal of Africa Nursing Sciences 3 (2015) 1–7
preparation for couples. This study highlights the need of formal
routine childbirth education made available to all pregnant women
to empower them especially the nulliparous pregnant women.
5.4. Clinical Implications
The findings from this study have significant implications for
the health care organizations. Antenatal anxiety must be taken
care as a top priority to reduce emerging number of caesarean sec-
tions and other adverse pregnancy outcomes. A formal antenatal
screening for pregnancy-specific anxiety should be a part of rou-
tine antenatal check up to identify the high risk groups of pregnant
women with pregnancy anxiety and fear. The findings of the pre-
sent study suggest the necessity of implementing interventions
to reduce pregnancy-specific anxiety and thereby positively influ-
ence birth outcomes. The increasing number of maternal request
for cesarean birth because of high childbirth fear and anxiety can
be reduced when proper attention is given to reduce
pregnancy-specific anxiety especially among nulliparous women.
Authors recommend the implementation of a structured childbirth
education for pregnant women as part of the routine antenatal care
both in public and private hospitals to ensure well-informed and
empowered expectant mothers, which would reduce their preg-
nancy related anxieties. This study emphasises the need to
empower nulliparous women through planned childbirth educa-
tion to reduce their childbirth anxiety. The authors recommend
that childbirth education must be made available in all health care
agencies especially in the current setting. Future research is
needed to explore the impact of childbirth education on
pregnancy-specific anxiety.
6. Conclusion
The study highlights that even with good family support and
marital harmony pregnant women in Kerala, India reported high
prevalence of pregnancy-specific anxiety especially childbirth anx-
iety. Nulliparous status, young age and nuclear family status were
the identified risk factors of PSA. The high prevalence of
pregnancy-specific anxiety could be attributed to low perceived
knowledge on childbirth and parenting due to the lack of formal
childbirth education in the era of nuclear family norm. This study
emphasises routine screening of pregnant women for
pregnancy-specific anxiety and provide early preventive measures
to reduce pregnancy-specific anxiety which would reduce the
adverse pregnancy outcomes. The authors recommend a formal
childbirth education for pregnant women in all hospitals in
Kerala to enhance childbirth preparation and empower women
to cope with the changes and challenges of pregnancy and
childbirth.
Conflict of interest statement
There are no organisations with conflict of interest related to
the study. The co-authors declare that they have no competing
interests.
Funding statement
The study was self-financed.
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