Screening for perceived stress among pregnant women availing antenatal care at a tertiary care teaching institution in Kerala, India

Heera Shenoy T., Remash K., Sheela Shenoy T.


Background: Stress during pregnancy can have serious adverse outcomes on the mother, the foetus and the new-born. It can lead to low-birth-weight, preterm births and neuro-psychological effects such as anxiety and depression during pregnancy and puerperium. This cross-sectional research aims to assess the severity of stress among postnatal women in Kerala. This study analysed socio-demographic, obstetric, family dynamics, neonatal characteristics and psychiatric determinants of postpartum stress using perceived stress scale (PSS) among postnatal women in a tertiary hospital in Kerala state, India.

Methods: 119 women between 2 to 6 weeks of postpartum period were subjected to a pre-tested pre-structured standard questionnaire. Terminal illness, still birth delivery and comorbid psychiatric illness was excluded. Screening and diagnosis of postpartum stress was done based on perceived stress scale (PSS) and graded as mild 0-13, moderate 14-26, severe 27-40.

Results: Study findings indicated a statistically significant association between postpartum stress and risk factors such as unplanned/unwanted pregnancy. The mean age of women was 27±4.8 years. Support from spouse and in-laws was a negative predictor of developing both postnatal stress and depression. Family income, education of couple and husbands’ occupations were non-determinant factors (p>0.05) in this study. Psychiatric illness in the family and past history of psychiatric illness also contributed to postnatal stress. The most important variable which influenced perceived stress during pregnancy was lengthier NICU stay. Even breastfeeding problems and associated neonatal issues worsened the stress scales significantly in the immediate postnatal period.

Conclusions: This research concluded that stress detection and timely counselling along with mental and physical support will mitigate stress and postpartum depression.


Determinants, Perceived stress scale, Post-partum depression, Postnatal stress, Risk factors, Social factors, Screening

Full Text:



Elsenbruch S, Benson S, Rücke M, Rose M, Dudenhausen J, Pincus-Knackstedt MK, et al. Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome. Human Reprod. 2007;22(3):869-77.

Talley L. Stress management in pregnancy. Int J Childbirth Educat. 2013;28(1):1.

Ruiz R, Fullerton J. The measurement of stress in pregnancy. Nurs Health Sci. 1999;1(1):19-25.

Littleton HL, Breitkopf CR, Berenson AB. Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis. Am J Obstet Gynecol. 2007;196(5):424-32.

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385-96.

Huizink AC, Anja C. Prenatal stress exposure and temperament: a review. Eur J Dev Sci. 2008;2:77-99.

Shiva KBK, Krishnamurthy CN. Psychological factors affecting outcome of pregnancy. Ahhs. 2015;2(1):44-9.

Philipp M, Brede ME, Hadmek K, Gessler M, Lohse MJ, Hein L. Placental alpha-2 adrenoreceptors control vascular development at the interface between mother and embryo. Nat Genet J. 2002;31(1):311-5.

Bale TL, Baram TZ, Brown AS, Goldstein JM, Insel TR, McCarthy MM. Early life programming and neurodevelopmental disorders. Biol Psych. 2010;68(4):314-9.

Bilbo SD, Schwarz JM. Early-life programming of later-life brain and behavior: a critical role for the immune system. Frontiers Behavioral Neurosci. 2009;3.

Divney AA, Sipsma H, Gordon D, Niccolai L, Magriples U, Kershaw T. Depression during pregnancy among young couples: The effect of personal and partner experiences of stressors and the buffering effects of social relationships. J Pediatr Adoles Gynecol. 2012;25(3):201-7.

Verbeek T, Bockting CL, van Pampus MG, Ormel J, Meijer JL, Hartman CA, et al. Postpartum depression predicts offspring mental health problems in adolescence independently of parental lifetime psychopathology. J Affect Disord. 2012;136(3):948-54.

Holzman CD, Eyster J, Tiedje LB, Roman LA, Seagull E, Rahbar MH. A life course perspective on depressive symptoms in mid-pregnancy. Maternal Child Health J, 2006;10(2):127-38.

Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5-14.

Records K, Rice M. Psychosocial correlates of depression symptoms during the third trimester of pregnancy. J Obstet Gynecol Neonat Nurs. 207;36(3):231-42.

van Os J, Selten JP. Prenatal exposure to maternal stress and subsequent schizophrenia. The May 1940 invasion of The Netherlands. The Br J Psychiatr. 1998;172(4):324-6.

Khashan AS, Abel KM, McNamee R, Pedersen MG, Webb RT, Baker PN, et al. Higher risk of offspring schizophrenia following antenatal maternal exposure to severe adverse life events. Arch General Psyc. 2008;65(2):146.

Dunkel Schetter C. Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues. Annual Review Psychol. 2011;62:531-58.

Da Costa D, Dritsa M, Verreault N, Balaa C, Kudzman J, Khalifé S. Sleep problems and depressed mood negatively impact health-related quality of life during pregnancy. Arch Women's Mental Health. 2010;13(3):249-57.

Lau Y, Yin L. Maternal, obstetric variables, perceived stress and health-related quality of life among pregnant women in Macao, China. Midwifery. 2011;27(5):668-73.

Kingston D, Heaman M, Fell D, Dzakpasu S, Chalmers B. Factors associated with perceived stress and stressful life events in pregnant women: findings from the Canadian maternity experiences survey. Maternal Child Health J. 2012;16(1):158-68.

Whitehead N, Brogan D, Blackmore-Prince C, Hill H. Correlates of experiencing life events just before or during pregnancy. J Psychosomat Obstet Gynecol. 2003;24(2):77-86.

Lever JP. Poverty, stressful life events, and coping strategies. The Spanish J Psychol. 2008;11(1):228-49.

Glazier RH, Elgar FJ, Goel V, Holzapfel S. Stress, social support, and emotional distress in a community sample of pregnant women. J Psychosom Obstet Gyneacol. 2004;25(3-4):247-55.

Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry. 2004;49(11):726-35.

Alder J, Fink N, Bitzer J, Hösli I, Holzgreve W. Depression and anxiety during pregnancy: a risk factor for obstetric, foetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med. 2007;20(3):189-209.

ACOG committee psychosocial risk factors perinatal screening and intervention. Obstet Gynecol. 2006;108:469-77.

Nath A, Murthy G, Babu G, Di Renzo G. Effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru, southern India: a prospective cohort study. BMC Psychiatry. 2017;17(1):255.

Madhavanprabhakaran GK, D’Souza MS, Nairy KS. Prevalence of pregnancy anxiety and associated factors. IJANS. 2015;3:1.

Goyal D, Gay C, Lee KA. How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Women’s Health Issues. 2010;20(2):96-104.

Woods SM, Melville JL, Guo Y, Fan MY. Psychosocial stress during pregnancy. Am J Obstet Gynecol. 2010;202(1):e61-7.

Farkas C, Valdés N. Maternal stress and perceptions of self-efficacy in socioeconomically disadvantaged mothers: an explicative model. Infant Behav Develop. 2010;33(4):654-62.

Renae Stancil T, Hertz-Picciotto I, Schramm M, Watt-Morse M. Stress and pregnancy among African- American women. Paediatr Perinat Epidemiol. 2000;14(2):127-35.

Öhmann SG, Grunewald C, Walndenström U. Women’s worries during pregnancy: testing the Cambridge Worry Scale on 200 Swedish women. ScandJ Caring Sci. 2003;17:148-52.

Lobel M, Cannella DL, Graham JE, DeVincent C, Schneider J, Meyer BA. Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychol. 2008;27:604-15.

Alqahtani AH, Al Khedair K, Al-Jeheiman R, Al-Turki HA, Al Qahtani NH. Anxiety and depression during pregnancy in women attending clinics in a university hospital in eastern province of Saudi Arabia: prevalence and associated factors. Int J Womens Health. 2018;10:101-8.

van Heyningen T, Honikman S, Myer L, Onah MN, Field S, Tomlinson M. Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study. Arch Womens Ment Health. 2017;20(6):765-75.

Cheng ER, Rifas-Shiman SL, Perkins M. The influence of antenatal partner support on pregnancy outcomes. J Womens Health (Larchmt). 2016;25:672-9.

Johnson AR, George M, Goud BR, Sulekha T. Screening for mental health disorders among pregnant women availing antenatal care at a government maternity hospital in Bengaluru City. Indian J Psychol Med. 2018;40:343-8.

Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2:6.

Dozier AM, Nelson A, Brownell E. The relationship between life stress and breastfeeding outcomes among low-income mothers. Adv Prev Med. 2012;2012:902487.