Assessment of perceived stress and associated factors among pregnant women attending antenatal care at Arba Minch town governmental health institutions, southern Ethiopia, 2020

Introduction : Perceived stress is a real or apparent inconsistency between environmental 25 demands required for survival and an individual’s capacity to adjust to these requirements. Worldwide stress is a very common problem. Females are at increased risk to develop 27 perceived stress in antepartum period. Stress during pregnancy has serious effects for both 28 the mother and newborn. However this problem doesn’t get adequate attention during 29 antenatal care in Ethiopia. Objective : To assess the magnitude of perceived stress and associated factors among 31 pregnant women attending antenatal care at Arba Minch town governmental health institutions, Southern Ethiopia, 2020 33 Methods : Institution based cross-sectional study was employed from March 16 to April 23, 34 2020. A total of 460 mothers were included in the study. Systematic sampling was used to 35 select participants. Data were collected using structured pretested questionnaire, entered in to 36 epi data version 3.1 and then exported to SPSS version 25 for analysis. A bivariable and 37 multivariable logistic regression analysis was used to identify factors associated with 38 outcome variable and variables with P value <0.05 in the final model were considered 39 statistically significant. 40 Result : The magnitude of perceived stress during pregnancy was 23.1% (95% CI; 19.16- 41 26.96%). Multigravida (AOR= 3.95, 95% CI; 1.94 – 8.02), ANC initiation <16 weeks of 42 gestation (AOR= 2.05, 95% CI; 1.18 – 3.57), first trimester (AOR= 3.03, 95% CI; 1.34 – 43 6.85) and unplanned pregnancy (AOR= 4.32, 95% CI; 2.55 – 7.31) were associated factors of 44 perceived stress during pregnancy. Conclusion and recommendation : The findings showed that the magnitude of perceived 46 stress during pregnancy is high. Gravidity, time of ANC initiation, gestational age and status of pregnancy were statistically significant associated factors of perceived stress during 48 pregnancy. Assessment and provision of emotional support for pregnant women is very crucial. AD: Developed design, coordinated the study, performed statistical analysis and sequence alignment, and drafted the manuscript. WE: Participated on Design development, performed statistical analysis, participated drafting the manuscript. GE: Coordinated the study, 423 developed design, statistical analysis and participated manuscript draft development. WA: 424 Coordinated the study, entered data, participated in developing the document KB: 425 Participated on Design development, entered data and participated manuscript draft 426 development. TW: Coordinated the study, entered data, participated in developing the 427 document. All these authors read and approved the final manuscript. 428


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Stress is an actual or perceived disparity between environmental demands required for 53 existence and an individual's capacity to adapt to these desires (1). Perceived stress during 54 pregnancy is defined as the disparity that a gravid lady feels when she cannot deal with 55 demands and worries (2). Pregnancy is considered stressful period that may provoke mental 56 illness and low level of perceived stress during pregnancy is good for the most favorable 57 development of the fetus, but if it goes beyond it may lead to long term effect on the fetus, 58 and change the development of the fetal nervous system (3). 59 Stress during pregnancy is a very common problem with nearly three-quarters of women 60 reported they had experienced at least one stressful event before the delivery of their child (4). 61 In Africa studies employed in democratic republic of Congo, Nigeria and Ghana show that the 62 prevalence of perceived stress during pregnancy was 57.1%, 46.7% and 28.6% respectively 63 (25-27). Similarly the study conducted in Ethiopia shows that the prevalence of perceived 64 stress during pregnancy is 11.6% (8). 65 Maternal stress can lead to increased rates of infant mortality, low birth weight and preterm 66 birth, which may have long term negative consequences for health and development of the 67 child (5). Studies have shown that women experiencing high stress are 1.5 to 3 times more 68 likely to experience preterm delivery than less stressed women (6). In order to prevent the 69 adverse outcome of stress during pregnancy for both the mother and fetus it is necessary to 70 screen and provide appropriate support during antenatal period by nurses, midwives, 71 obstetricians and mental health specialists (7). Even though majority of pregnant woman's 72 attend antenatal care which is recommended by world health organization current antenatal 73 care is ill-equipped to identify women suffering from high levels of stress or it does not assess 74 emotional status of pregnant mothers (8). In Ethiopia the antenatal care guideline does not 75 assess the emotional status of the pregnant mothers (9). 76 The study conducted in Ethiopia, Bale zone from November 2016 to April 2017 shows that; 77 among 386 pregnant mothers enrolled in the study the prevalence of perceived stress was 78 11.6% (9). The magnitude of perceived stress was 12.4% in Iran, 6% in United states of 79 America, 7.33% in Ardabil Iran and 17.2% in Canada (39,7,40,28). Other studies shows that 80 the magnitude of stress in Saudi Arabia was 33.4%, Ghana 50%, Democratic republic of 81 Congo 57.1%, Nepal 34%, America 28% and Ghana 28.6% (41,29,25,42,37,27). 82 Multiple investigations indicate that multigravida mothers are highly considered to have 83 perceived stress when compared with primigravida mothers (8,36). In opposite studies 84 conducted in Northern Ireland and Bangalore shows that multigravidas had low prenatal stress 85 and primigravida have significant association with perceived stress during pregnancy (35,12).

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Perceived stress is also high among mothers who initiate antenatal care after 16 weeks of 87 gestation (10). The study conducted in Ethiopia indicates that gestational age less than twelve 88 weeks or first trimester is positively associated with perceived stress during pregnancy (9).

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Studies conducted in different parts of the world show that unplanned pregnancy is 90 significantly associated with perceived stress during pregnancy (10,11).

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During antenatal care follow up pregnant mothers are not scanned to diagnose stress and due 92 to this fact it's difficult to identify which women are stressed (12). To the investigator 93 knowledge, there is only a single study done in Ethiopia among pregnant mothers but it lacks 94 important variables. Those missed variables include psychosocial variables like social 95 support, sexual abuse, women concern about husband, family support, husband financial and 96 emotional support. Additionally the prevalence and contributing factors of perceived stress 97 which is representative of all women of the antenatal period is not studied specifically in 98 study area. Therefore, this study aimed to address perceived stress in pregnant mothers by 99 adding some important variables. governmental health institutions, southern Ethiopia, 2020 (7,8,9,   Perceived stress: perceived stress is the imbalance that a pregnant woman feels when she 173 cannot cope with demands, which is expressed both behaviorally and physiologically.

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Perceived stress scale is scored by summing across all scale items. The total score ranges 175 from 0.0-21.0 with higher scores indicating women with more perceived stress symptoms.

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The cutoff value for the stress limit was set at 15 (9,13,14). were counseled on danger signs of pregnancy (Table 2).     (Table 3).   The mean value of perceived stress among pregnant women was 12.64 ± 2.8 (mean ± SD).   Factors associated with perceived stress during pregnancy 296 The association between perceived stress and its associated factors among pregnant mothers 297 was analyzed using binary logistic regression. All factors which have a p-value <0.25 in 298 bivariable analysis were considered to multivariable logistic regression model. with in first trimester of pregnancy had perceived stress 3.03 times higher than mothers with 312 in third trimester (AOR= 3.03, 95% CI; 1.34-6.85). The likelihood of having perceived 313 stress was about 4.32 times higher for mothers who has unplanned pregnancy (AOR= 4.32, 314 95% CI; 2.55 -7.31) as compared to those mothers whose pregnancy was planned (Table 5). This study finding shows that perceived stress during pregnancy was higher for mothers 369 whose pregnancies were unplanned than mothers whom pregnancies were planned. This

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Stress during pregnancy might also occur among women with unplanned pregnancy due to 379 their occupational status since the pregnancy of majority of students were unplanned and 380 with increasing maternal age the chance of occurrence of unplanned pregnancy is higher and 381 this can also leads stress during pregnancy.

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Strengths of the study 383 Many variables were addressed and assessed.

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Limitations of the study 385 This study was an institution-based study; hence findings may not reflect the stress of all 386 pregnant women in the community. Social desirability bias could also be a concern. The 387 cross-sectional study could not help the researcher to establish cause -effect relationship.

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The magnitude of perceived Stress during pregnancy was high among pregnant women Perceived stress scale among pregnant women attending antenatal care units of Arba Minch town governmental health institution, southern Ethiopia, 2020 (n=451)