The main goal of the present study was to analyze the psychometric properties of the Italian version of NuPCI in three groups of women assessed in different trimesters of their pregnancy.
In the literature, most of the studies considered coping styles in high-risk or complicated pregnancies [35], even if they represent a low percentage of the total gestations (i.e., about 12% of the pregnancy in the Italian population) [36].
This study had focused on low-risk pregnant women to assess stress expression and coping strategies in typical situations. Furthermore, the sample included women in different trimesters of pregnancy. Many studies had focused on specific periods of pregnancy and only a few had examined coping across all pregnancy [7]. This is an important point because it is well known that stressors undergo main changes during pregnancy, probably with concomitant modifications in the coping strategies (e.g., [26]).
In our sample, no statistically significant heterogeneity was found for socio-demographic characteristics, general coping strategies (Brief-COPE), and levels of general (STAI) and pregnancy-specific (NuPDQ) stress among the three trimesters. Thus, the comparison between by-trimester samples in terms of coping strategies is reliable.
Internal consistency
The Italian version of NuPCI showed good internal consistency (Cronbach’s coefficient alpha) for Planning-Preparation and Spiritual-Positive Coping scales and an acceptable level for Avoidance scale. These results, obtained both for the total sample and for the single trimesters, are in line with those reported for the North-American version of NuPCI [11] and with the outcomes of different validation studies conducted worldwide (i.e., for NuPCI Spanish and Persian versions) [14, 24]. The exploratory factor analysis conducted on the 32 items included in NuPCI scales found a three-factor solution close to that proposed by Hamilton and Lobel [11]. Consistently, the three factors were labeled: Planning-Preparation (Factor 1), Spiritual-Positive Coping (Factor 2), and Avoidance (Factor 3). The 32 items followed expectations, except for the items 27 and 39 (that showed low loadings in all factors), and item 9 (that resulted more associated to Spiritual-Positive Coping rather than to Planning-Preparation). Despite these differences, the scales were one-dimensional. It was therefore preferred to maintain the standard scoring method, to improve comparability with the original instrument.
Differently from the results of the original instruments, we observed correlated scale scores. In particular, the Planning-Preparation scale positively correlated with both Spiritual-Positive Coping and Avoidance scales and a trend towards a significant correlation was found between the last two. Apparently, in the Italian population, the Planning-Preparation scale shares some aspect of the other two NuPCI scales.
Convergent validity of coping scales
The Planning-Preparation was the most used coping style (the mean of the total sample is in “Sometimes” range), a result in line with Lorén-Guerrero’s work [24] but different from North-American results [11], in which women have been shown to use mainly Spiritual-Positive Coping. These discordant results could be explained by differences in samples: low-risk pregnancies were considered in our and the Spanish studies, while Hamilton and Lobel’s work included also high-risk women. Besides, this scale significantly increased comparing the first trimester to the second and third ones, differently from the North-American sample [11], in which Planning-Preparation was stably used across all the three trimesters. However, here cross-sectional observations were reported, while in the original work the same women were longitudinally followed across the entire gestation. This scale was positively correlated to the Self-Distraction Brief-COPE subscale. Also, a positive trend to statistical significance was found for both Adaptive and Maladaptive Brief-COPE categories and for Use of emotional support, Use of instrumental support and Positive reframing subscales.
The Spiritual-Positive Coping style was used with a lower frequency than in the original sample (i.e., between “Rarely” and “Sometimes”) and with no differences between the trimesters. The Spiritual-Positive Coping scale was correlated with the Adaptive Coping scale and with Religion Brief-COPE subscale. These results confirmed that the scale is a direct measure of adaptive coping strategies.
Avoidance coping was the least common employed strategy, a result in line with many previous studies [11, 24]. As expected, the Avoidance scale significantly correlated with the Maladaptive Brief-COPE category and with Denial, Use of emotional support, Use of instrumental support, Behavioral disengagement and Self-blaming subscales. Also, trends to statistical significance were found for Self-Distraction and Venting subscales.
Concurrent validity
We analyzed how coping strategies measured with NuPCI could predict PSS, as measured with NuPDQ. In our sample, NuPDQ demonstrated a good construct validity, since total score was correlated with STAI State and Trait scales. In particular, there was a strong correlation with the State scale of STAI, which has often been used to assess PSS [37, 38]. All NuPCI scales were associated with NuPDQ score, but with different directions. Avoidance and Planning-Preparation scales positively predicted the NuPDQ score, with higher scores corresponding to greater perceived stress. Particularly, the Avoidance score showed a medium-size association with stress, so that the increase of one in this scale roughly corresponds to an increment of five in NuPDQ (or about half standard deviation for each standard deviation in predictor). According to a systematic review [1], avoidant approach affects mental health outcomes during pregnancy (and post-partum), increasing perceived stress, depression, anxiety, and subsequent child abuse. Moreover, avoidance coping has been associated with a higher level of corticotrophin-releasing hormone of placental origin (pCRH), which may lead to a preterm delivery [39, 40]. On the contrary, the Spiritual-Positive Coping scale negatively predicted the NuPDQ score (i.e., the higher was the score, the lower was the perceived stress). This finding is in line with the literature, where Spiritual approach had been linked with lower levels of stress in pregnant women without any risk [41]. Interestingly, in high-risk pregnant women, Spiritual-Positive Coping style has been instead associated with greater stress [42], suggesting that prayer could be seen as a form of rumination, rather than a reaction that gives relief [15].
Predictive validity
The coping strategies showed significant effects in predicting Apgar score in the 3rd trimester sample, so that the linear model explained 17% of its variance (where the covariates only explained the 7% of it). Furthermore, in this group, the level of pregnancy-specific stress assessed with PDQ moderated the predictions of coping strategies (i.e., with the 24% of explained variance). Considering the moderating level of stress, a mother's Avoidance style in the third trimester was associated with a worsening of the baby's ability to tolerate the birth process, while a Spiritual-Positive coping was associated with an improvement in this capacity. Inconsistent results have been previously reported considering the association of stress and Apgar score [20], recommending that birth status could be better predicted with mediating factors [43] or multiple moderators [19]. Our preliminary results suggest a significant role of coping strategies, and in particular those close to the childbirth.
Limitations
The main limitation of this work is the adopted cross-sectional design. Thus, it was not possible to examine the test-retest reliability of the Italian NuPCI and to follow the same women through pregnancy. Nevertheless, this was partially overcome by the homogeneity observed in the three trimesters. Another limitation is the relatively low sample size, even though it is in line with other validation studies [14, 24, 44]. A further limitation could be that some of the correlations between NuPCI and Brief-COPE scales statistically significant at ≤ 0.002 were moderate in absolute terms. Finally, choosing to include only women with low-risk pregnancies does not allow to observe the burden of stress related to pathological conditions on pregnancy.