Factors Influencing Stress, Anxiety, and Depression Among Iranian Pregnant Women: The Role of Sexual Distress and Genital Self-image

Abstract

Background: Pregnancy is a unique period with the increased likelihood of psychological changes and emotional disturbances such as depression, anxiety, and stress. In this study, we investigated the factors influencing depression, anxiety, and stress in pregnancy and identify their associations with Sexual Distress (SD) and Genital Self-Image(GSI).  

Methods: This was a descriptive, correlational, cross-sectional study performed between September 2019 and January 2020. Overall, 295 pregnant women completed a demographics and obstetric information checklist, Depression Anxiety and Stress Scale-21 (DASS-21), Female Genital Self-Image Scale (FGSI), and Female Sexual Distress Scale-Revised (FSDS-R).

Results: The mean score of SD was significantly associated with the severity of depression, anxiety, and stress. Also, the mean score of GSI was negatively correlated with the severity of depression and anxiety. Multiple linear regression analysis revealed that the risk factors for depression include SD, fear of fetal abortion, bad experience in previous pregnancy, poor GSI, and advancing age, whereas satisfaction with income was a protective factor. SD, fear of fetal abortion, and increased duration of marriage were found to be associated with the development of anxiety symptoms, whereas satisfaction with income, positive body image, and increased gestational age had a protective effect against this variable. SD, adverse events in previous pregnancies, and advancing age were the risk factors, while planned pregnancy and increased gestational age were the protective factors against developing stress during pregnancy. 

Conclusion: Many factors influence the development of depression, anxiety and stress in pregnancy, which may be different or common. Some of these factors are avoidable and some are not. Therefore, considering all the factors comprehensively with emphasis on the improvement of preventable factors by screening and counseling can be useful for mothers and their fetuses.

Background

Pregnancy is one of the most critical periods with considerable changes in women’s physical, mental, and sexual states [1]. During this period, vulnerability to emotional and psychological conditions such as depression, anxiety, stress, and psychosis is increased, which can lead to maternal and fetal adverse consequences [2].

The rates of the common mental disorders during pregnancy such as depression and anxiety range from 4–25% in different studies [3, 4]. In one study, the prevalence rates of prenatal stress, anxiety, and depression in during the first weeks of pregnancy were reported 91.86%, 15.04% and 5.19%, respectively [5]. The findings of an Iranian study also reported the rates of depression, anxiety, and stress to be 31.7%, 32.5%, and 49.1%, respectively[6]. The combination of maternal depression, stress, and anxiety can cause preterm labor, preeclampsia, and fetal neurodevelopmental problems [7].

Many factors seem to affect the mental state of pregnant women. In a study by Tang et al., it was reported that anxiety, low social support, and poor and/or moderate-level family care were the risk factors for prenatal depression. The risk factors for prenatal anxiety included unemployment, primiparity, stress, depression, and low social support. In addition, unemployment, anxiety, and low- and moderate-level social support were found to be associated with the development of prenatal stress [5]. There are limited studies on the effect of Sexual Distress (SD) and Genital Self- Image (GSI) on prenatal stress, anxiety, and depression.

SD is considered as a state of experiencing negative emotions such as embarrassment, blaming, frustration, anxiety, fear, and anger in one’s sexual life [8]. Decreased sexual desire [9], worry, fear of harm due to sexual activity [10], notable changes in Body Image (BI) and appearance [11], and poor adaptation to sexual changes and parental role [12] can be considered as the main factors instigating SD during pregnancy. In Canadian and American population-based studies of pregnant women, 40% were found to experience SD during pregnancy [13]. However, it is unclear whether increased SD can lead to development of anxiety, depression, or stress during this period.

Another factor that seems to be associated with mental distress during pregnancy GSI. It is a subcategory of BI [14], which is defined as one’s perception and experience of their genitals, such as appearance, odor, and functionality [15]. During pregnancy several alterations occur throughout the body, including weight gain and skin changes [16]. In the study by Earle, pregnant women expressed concerns regarding how they would look as their pregnancy advances, which parts of their body would change, and how hard it would be to get back to their pre-gestational body shape [17]. The genital area is one of the most important areas of the body that undergoes different changes during pregnancy [18]. It has been found that BI perception levels decline during pregnancy [16]. Some studies have investigated the relationship between BI and prenatal mental disorders such as depression [19, 20], which showed that poor BI during the third trimester of pregnancy is a risk factor for post-partum depression [21]. However, pregnant women's perceptions about their genitals and its relationship with mental disorders such as depression, anxiety, and stress during pregnancy is still uncertain.

Various factors are known to cause or exacerbate depression, anxiety, and stress during pregnancy. Thus, promoting awareness regarding the risk factors for depression, anxiety, and stress during pregnancy based on regional and cultural contexts is critical in planning and implementing prenatal care programs because of the unique characteristics of this period.

Therefore, the aim of this study is to determine the associations of depression, anxiety, and stress with SD and GSI and to identify the other factors influencing the development of depression, anxiety and stress during pregnancy in an Iranian population.

Methods

Study Population and Design

This cross-sectional survey was performed between September 2019 and January 2020 using the two-stage cluster sampling method in Amol, north of Iran. It must be noted that this study is presented according to Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines [22].

First, four healthcare centers in four regions of Amol city (north, south, east and west) were randomly selected. Second, pregnant women were selected by the systematic sampling method from the Department of Midwifery of each center. The sample size from each center was determined based on the probability of selection in proportion to population size. Then, the pregnant women meeting the inclusion criteria were explained the purpose and nature of the study and signed an informed consent from.

The inclusion criteria consisted of healthy pregnant women, women with singleton pregnancy in all trimesters, living with the spouse at the time of recruitment, and willingness to participate in the study. The exclusion criteria were women with contraindication for sexual intercourse (for any reason), women with any medical illness and/or complication in the current pregnancy, and women fertilized via assisted reproductive techniques. 

Sample Size

In a study on pregnant women, the mean and standard deviation of anxiety score using the Depression, Anxiety and Stress scale (DASS-21) in Iran was 4.23 (SD= 4.23)[23]. With an estimated precision of 50% (d =0.5), confidence level of 95% (α) (Z = 1.96), and an attrition rate of 15%, the final sample size was estimated at 323 pregnant women. 

Measures

Four instruments were applied for data collection, including Depression Anxiety and Stress Scale-21 (DASS-21), Female Sexual Distress Scale-Revised (FSDS-R), Female Genital Self-Image Scale (FGSI), and a socio-demographics checklist for sample characterization.

Socio-demographics Checklist

This checklist was composed of objective questions designed by the researchers and contained socio-demographic (i.e., age, duration of marriage, women’s education, women’s occupation, satisfaction with income) and obstetric (parity, planned pregnancy, history of abortion, complications in previous pregnancy, gestational age, and fear of fetal abortion) questions. It also asked about satisfaction with foreplay and BI.

Depression Anxiety and Stress Scale-21 Item (DASS-21)

In this study, the validated version of the short form of Depression Anxiety Stress Scale (DASS-21) was used to evaluate depression, anxiety, and stress during pregnancy. Seven items are assigned for the evaluation of depression, anxiety and stress. Each item is scored from never (0) to very high (3), with higher scores indicating greater levels of depression, anxiety and stress. In an English study, the Cronbach's alpha was reported 95% for depression, 90% for anxiety, 93% for stress, and 97% for the overall score [24].  The reliability coefficients of the Persian version of the DASS-21 were reported 94%, 92%, and 82% for the domains of depression, anxiety, and stress, respectively [25], indicating its reliability and validity among Iranian samples. The scoring method is presented in the following table [26].

Results

Discussion

This study contains important data about factors related to depression, anxiety, and stress in pregnant women. It is important to be aware of the factors contributing to the development of depression, anxiety, and stress, pay attention to these factors in prenatal care, and offer counseling strategies to reduce the depression, anxiety, and stress perceived by pregnant women based on the factors causing them. Therefore, these data can be used for planning antenatal care and future studies.

The present study demonstrated that female SD was a significant factor contributing to depression, anxiety, and stress. Moreover, increased severity of SD in pregnancy was associated with elevated severity of depression, anxiety, and stress. Although many studies have examined sexual function in pregnancy, few have examined SD during this period. In addition, no study has yet been conducted to investigate this factor as an influential factor in depression, anxiety, and stress during pregnancy. A study of non-pregnant samples showed a significant relationship between anxiety and stress and all aspects of sexual function, except for sexual desire and pain. It also revealed a significant association between depression and all aspects of sexual function except for sexual pain [26]. Since women with sexual problems may report concurrent SD [32], it seems that SD is also associated with anxiety, depression, and stress. On other hand, a high rate of SD in pregnancy has been reported. A study by Sarah showed that 42% of women experience SD during pregnancy, which can be in the presence or absence of a sexual problem [13]. This rate of SD is slightly higher than the rate reported in Finnish and American population-based studies of women who were not pregnant [32, 33]. It seems that SD is more common in pregnancy due to the unique features of this period. For this reason, it is important to consider the role of SD in the development of depression, anxiety, and stress, followed by providing counseling and treatment techniques that improve it.

We found that women with poor GSI were at a higher risk for depression. Indeed, we noted a significant inverse correlation between GSI score and depression and anxiety scores, such that as BI score decreased, the scores of depression and anxiety increased. In other words, having a poor GSI was associated with high severity of depression and anxiety. In this regard, satisfaction with BI in pregnancy was also recognized as an effective factor in antenatal anxiety. In a critical review of the literature, it was reported that all prospective cohort studies evaluating the impact of BI on the incidence of depression found a positive relationship between BI dissatisfaction and incidence of prenatal depression. Moreover, this review examined whether depression leads to BI dissatisfaction. It was noted that the findings of studies are inconsistent regarding the effect of depression on BI [19]. As it is known, pregnancy induces a variety of hormonal, immunologic, and metabolic changes that exert significant effects on a woman’s body. Pregnancy can trigger or intensify negative feelings about the body. Some women can be distressed by bodily changes in pregnancy. BI dissatisfaction during pregnancy can have a negative impact on both the mother and the baby [34]. One of the areas most affected by pregnancy changes is the genitals (i.e., hyperpigmentation, volva skin stretch, striae on volva, mucosal changes, etc.) [18]. Both BI dissatisfaction and poor GSI can indirectly cause stress and anxiety and affect sexual function [35, 36], and subsequently, engender SD. Many studies have reported a link between GSI and sexual function in the non-pregnant population. Since pregnant women are more prone to poor GSI due to changes in their physiology, special attention should be paid to the role of this factor in the development of mental disorders.

Planned pregnancy was revealed to be a significant factor for developing depression and stress among participants in the present study. This finding has been corroborated by another study indicating the negative effect of unplanned pregnancy on antenatal depression. Biratu et al. [37] reported that women who had not planned the current pregnancy were 2.58 times more likely to develop antenatal depression than those who had planned the pregnancy. Many studies have reported unplanned or unwanted pregnancy as a risk factor for developing depression [37–39] and stress [40]. Various studies have emphasized the role of planned pregnancy in the prevention of antenatal depression [37]. In a systematic review conducted by Alessandra et al. [41], it was shown that unplanned or unwanted pregnancy is associated with antenatal depression. Hartley et al.[42] did not find a significant association between unwanted pregnancy and antenatal depression. Unplanned pregnancy can make a pregnant woman unhappy. Unhappiness could be the result of many contributing factors such as conflicts with others, life stress, and lack of social support. Sherin et al. [43] pointed out that being unhappy with the pregnancy is another risk factor associated with antenatal depression and women who were unhappy with their pregnancy were more likely to suffer from antenatal depression.

The present study demonstrated that adverse events in previous pregnancy (for any reason) was associated with depression and stress in the current pregnancy. This finding corroborates those of previous studies indicating that women with current or past pregnancy/delivery complications, history of pregnancy loss, pregnancy termination, or stillbirth have been found to be more likely to experience antenatal depression and anxiety. In the same vein, Waqas et al. [44] showed that a history of previous negative birth experience is linked with a high likelihood of antenatal depression. Bad/negative obstetric history such as history of miscarriage, stillbirth, and preterm birth were significantly associated with the increased risk of antenatal depression. This negative obstetric history and other pregnancy complications such as hyperemesis gravidarum, hypertension, and diabetes mellitus could also pose additional stress on mothers in current pregnancy [45]. An Italian study by Agostini et al. [46] also reported that a negative experience of pregnancy was significantly associated with antenatal depression. These findings show the importance of asking all pregnant women, regardless of their cultural differences, about history of experiencing any bad events for the mother or her fetus in a previous pregnancy.

We also found that fear of fetal abortion was a significant risk factor for anxiety, which it could be due to lack of experience in becoming a mother in primiparous women or due to bad experiences and complications in previous pregnancies in multiparous women. Therefore, it is necessary to ask about the fears and worries of pregnant women in prenatal care and provide appropriate counseling to reduce these negative feelings.

Satisfaction with income was another factor closely related to the decreased risk of prenatal depression and anxiety in this study, which is consistent with the results of other studies. For example, in a study by Brittain et al. [38] in South Africa, it was found that pregnant women with low socioeconomic status were more likely to experience antenatal depression than those with a high socioeconomic status. Another study also suggested that the higher prevalence of depression among black and Hispanic mothers could be mainly due to lower income and financial problems [3]. These findings were also supported by a recent systematic review by Fekadu Dadi et al. [47], which reported that pregnant women with a history of economic difficulties were more likely to report antenatal depression. Nevertheless, family income in a study conducted in Malaysia was not associated with depression and anxiety in pregnancy [48]. This discrepancy could be due to difference in study populations and measuring income levels using different categories.

In addition, we found a higher risk of anxiety in pregnant women with increased duration of marriage. It seems that in order to better understand this factor, special attention should be paid to the role of partner support. What’s more, increased age of women was revealed to be a significant risk factor for depression and stress, which could be because aging is associated with more pregnancy complications such as preeclampsia and worry about having these complications, which may lead to higher stress in women.

Our findings support the significant role of gestational age in the development of anxiety and stress, such that increased gestational age was associated with a decrease in stress and anxiety scores. Fadzil et al. [48] showed that gestational age less than 20 weeks was associated with antenatal anxiety. The risk of antenatal anxiety disorder was 4.85 times higher among mothers below 20 weeks of gestation compared to those 20 weeks and above. The probable reason for this finding is the increase in a woman's ability to cope with the physiological process of pregnancy and the physical changes occurring in her body over time.

Conclusions

Our study confirms that depression, anxiety, and stress are common during pregnancy and are associated with various risk and protective factors. This study demonstrates the necessity for psychiatric counseling based on predisposing factors for promoting the mental health of pregnant women and preventing adverse effects for the fetus in pregnancy. Therefore, it is recommended that midwives and nurses evaluate pregnant women for these risk factors and provide preventive care and, if necessary, refer pregnant women to a psychiatrist for treatment of the severe forms of these disorders.

Some limitations of the study should be noted. First of all, caution should be exercised in the interpretation of the data as the cross-sectional nature of the study does not show the causal relationship of the variables and correlational and longitudinal studies are needed to be conducted in the future. Although this study attempted to comprehensively examine the factors associated with mental disorders, some factors such as social support, satisfaction with the partner, and experience of domestic violence were not evaluated. Moreover, previous studies suggest that prenatal mental disorders often coexist and affect each other, but our study disregarded the role of one mental factor on another.

Abbreviations

SD: Sexual Distress; GSI: Genital Self-Image; BI: Body Image; DASS-21: Depression Anxiety and Stress Scale-21; SIDI-F: Sexual Interest and Desire Inventory-Female; FSDS-R: Female Sexual Distress Scale-Revised; STROBE: STrengthening the Reporting of OBservationally studies in Epidemiology; ANOVA: Analysis of Variance

Declarations

Ethics approval and consent to participate

The study was approved by the Research Ethics Committees of Shahroud University of Medical Sciences (Code: IR.SHMU.REC.1397.098, Date: 2018-09-05), and the necessary scientific permissions for sampling were obtained from Mazandaran University of Medical Sciences. It is worth noting that written informed consent was assigned by participants and was ensured of the confidentiality of the gathered information by the researcher.

Consent for publication

Not applicable.

Availability of data and material

The datasets for current study are available from the corresponding author on reasonable request.

Competing interests

None of the authors have a conflict of interest.

Funding

No funding was received for this study.

Authors contributions

All authors were involved in the drafting, editing and approval of the manuscript for publication. [MM]¹ and [AK] contributed to designing the study. [MM]¹ collected the data reported in this work. [MM]² contributed to interpretation of data. [NB] and [MRRS] contributed to writing and reviewing the manuscript. All authors read and approved the manuscript for submission.

Acknowledgements

We wish to thank all the pregnant women who agreed to participate in this study. Also, we would like to thank the Ethics Committee of Shahroud University of Medical Sciences and the healthcare center of Mazandaran University of Medical Sciences for cooperating with this study.

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