Stress and resilience during pregnancy: a comparative study between pregnant and non-pregnant women in Ethiopia

Background: Stress occurring during pregnancy is associated with perturbances in maternal psychology and physiology, and results in adverse pregnancy and birth outcomes. However, little attention has been given to understand maternal stress and its potential negative consequences in many low- and middle-income countries. We aimed to investigate whether pregnancy is associated with greater stress and lower psychological resilience among women living in Jimma, Southwest Ethiopia. Method: An institution-based comparative cross-sectional study design was implemented in Jimma University Medical Center from 15 September to 30 November 2021. Women attending antenatal care and family planning services were invited to participate in the study. Participants were interviewed using the Perceived Stress Scale (PSS-10), Brief Resilience Scale (BRS), distress questionnaire-5, and the Household Food Insecurity Access Scale (HFIAS). Linear regression analysis was used to test associations of pregnancy (exposure) with outcomes of stress and resilience scores, while adjusting for potential confounders. Stress and resilience were mutually adjusted for one another in the final model. Results: A total of 166 pregnant and 154 non-pregnant women participated, with mean age of 27.0 SD 5.0 and 29.5 SD 5.3 years respectively. Pregnancy was associated with increased stress score by 4.1 points ({beta}=4.1; 95% CI: 3.0, 5.2), and with reduced resilience by 3.3 points ({beta}=3.3; 95% CI: -4.5, -2.2) in a fully adjusted model. In mutually-adjusted models, pregnancy was independently associated with greater stress ({beta}=2.9, 95% CI 1.8, 3.9) and lower resilience ({beta}=-1.3, 95% CI: -2.5, -0.2) compared to non-pregnant women. Conclusion: In this low income setting, pregnancy is associated with greater vulnerability in the mental health of women, characterized by greater perceived stress and diminished resilience. Context-relevant interventions to improve resilience and reduce stress could help improve the health and wellbeing of mothers, with potential benefits for their offspring.


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The stress response, an adaptive component of physiology, represents a survival strategy during 55 exposure to threats, adverse experiences or stressors in life (1). When activated, the stress response 56 prepares the body for 'fight or flight' to promote safety and protection (1). However, chronic 57 activation of the stress response affects the body negatively and impairs health, wellbeing and 58 performance (2). The extent to which exposure to threats drives the perception of stress varies, 59 however, depending on an individual's ability to cope or adapt with stressors and successfully 60 bounce back to the normal homeostasis from the effect of adversities (3). The impact of stressors 61 on the stress response is mediated by coping and adaptive strategies, forms of resilience that buffer 62 the adverse effects on health and wellbeing (4). The development of psychological resilience is a 63 dynamic process across the life span formed as a product of the interaction between biological, 64 psychological and socio-environmental factors (5,6). People with different levels of resilience 65 therefore respond differently to a similar set of stressors, such that those with low resilience are 66 more prone to the adverse consequences of stress. 67 Women in low-income countries experience disproportionate levels of stressors related to 68 household responsibilities, as well as gender inequalities such as an elevated risk of malnutrition, 69 dietary inadequacy and violence (in particular intimate partner violence) (7). Moreover, emerging 70 evidence indicates that the state of pregnancy itself induce additional stress to pregnant women 71 (8). The transition in social role associated with becoming a mother (9) may be accompanied by 72 new physiological sources of stress, and potentially greater sensitivity to stress. This issue has 73 major implications for public health, as experiencing stress during pregnancy has consequences 74 not only for the mother, but also for the offspring who may be exposed to the physiological signals 75 of stress through the placenta (10-12). undermining optimal child development (30,31). The present study therefore aimed to investigate 99 whether pregnancy is associated with higher levels of stress and lower resilience, by comparing 100 these outcomes between pregnant and non-pregnant women in the city of Jimma, Ethiopia. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 3, 2022. The study was conducted in the urban setting of Jimma Zonal City, Oromia Region, Ethiopia.

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The city has two governmental hospitals, two private hospitals, five health centers, and more 107 than 10 private clinics. In addition, there are urban health extension workers providing maternal 108 and child health care services in the city. The total population of the city based on the 2021 109 projection is estimated to about 240,000. The study was conducted during the period September 110 to November, 2021.

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Design: 112 We employed an institution-based comparative cross-sectional study design.

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Population 114 We recruited pregnant and non-pregnant women aged between 18 and 40 years, attending 115 antenatal care and family planning services respectively at Jimma University Medical Center. 116 We invited consecutive women attending antenatal care and family planning services to 117 participate until we achieved the target sample size.

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Background characteristics: Information on age, parity, marital status, social support, religion, 120 family size, income, educational and occupational status was collected using a structured self-121 report questionnaire.

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Item 4, 5, 7 and 8 are positively phrased questions that required reverse coding during analysis.

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The sum score ranges between 0 (low level) to 40 (maximum level).

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Resilience assessment: Psychological resilience for various psychosocial stressors and stress 128 itself was assessed using the Brief Resilience Scale (BRS-6) (34) which contained 6 items scored . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint 129 as 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree) to the resilience 130 item statements (34). Item 2, 4 and 6 are negatively phrased and required reverse coding during 131 analysis. The sum score for resilience ranges from 6 (low resilience) to 30 (high resilience) 132 points.

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Exposure: For pregnancy status, women were classified as pregnant or non-pregnant as 134 confirmed by an obstetrician.

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Covariates: Additional variables on the following parameters were collected.      All data were entered into Epidata version 3.1 and transported to STATA-17 for analysis. The 154 data were checked for appropriateness and completeness before entry and then visualized and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint 155 cleaned using statistical software. Percentage and frequencies were used to describe categorical 156 data while mean and standard deviation (SD) or median and inter quartile range (IQR) were used 157 to describe continuous data depending on data distribution. The total scores of stress and further adjusted for stress score and resilience is the outcome variable. The same regression 176 models were repeated for each specific PSS-10 and BRS-6 items to identify items contributing 177 for the overall association between pregnancy and the total stress score or resilience score. Life

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(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. This study was approved by the IRB of Jimma University. Participant safety, privacy, and 187 confidentiality were ensured. All women were given information about the study and provided 188 their written consent for voluntary participation. The right not to participate or to withdraw from 189 the study was respected. All women during the study period were given equal opportunity to 190 participate in the study. Women with high stress scores were linked to a counseling service.

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(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022.   Table 2b. Linear regression analysis showed that pregnancy was associated with lower resilience 232 score in an unadjusted model (β=-3.6; 95% CI: -4.5, -2.6).  In adjusted analyses, except PSS item 1, all PSS item scores were significantly higher in 243 pregnant compared to non-pregnant women (Figure 3a). Numerical values are given in   (Figure 3b). Numerical values are given in Supplementary Table 2b. Linear regression . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Unlike previous studies, we used a comparative study design to measure the association of 285 pregnancy with stress and resilience so that we are able to investigate the independent 286 association of pregnancy with both outcomes. As such, the current study provides more robust 287 findings from a low income setting compared to previous work. family satisfaction, they can also be stressful experiences given uncertainty and concerns over 294 adverse outcomes for the pregnant women and the offspring, which can lead to a range of 295 negative psychological, physical, and mental consequences, all contributing to an increased state 296 of stress (44,45). In addition, pregnant women require an increased level of psycho-social 297 support to cope with the pregnancy alongside regular daily responsibilities; but in this study . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint around 72% of pregnant compared to 51% non-pregnant women reported that their social 299 support was inadequate. Moreover in a setting like Ethiopia where maternal mortality is high 300 (46,47), all pregnancies are considered to be "between life and death" and this situation increases 301 maternal stress significantly during pregnancy (8). All of these disadvantages that pregnant  Pregnancy is associated with stress and resilience in opposing directions in the current study.

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While perceived stress score was higher, resilience score was lower in pregnant compared to 308 non-pregnant women. At the first encounter, stressors/adversities affect or challenge an 309 individual's level of resilience or coping strategies and subsequently they progress to induce 310 stress (4). While resilience is the ability to absorb shock/stressors, stress is the product of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint 328 This is especially important for women during pregnancy to benefit both the mother and her 329 offspring, improving the health and productivity of the next generation by breaking the 330 intergenerational transmissions of stress.

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The fact that women in general have higher stress score in the current study could indicate the  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint 358 Perceived stress is higher and resilience is lower in pregnant women compared to non-pregnant 359 women in Ethiopia. There is a need for more research into the different stress response 360 mechanisms and stress biomarkers during pregnancy. Moreover mechanistic studies and context 361 relevant interventions to improve psychological coping and resilience, and to reduce stress are 362 required so as to improve the health and wellbeing of the mother and her offspring. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted December 3, 2022.

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. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 3, 2022. ; https://doi.org/10.1101/2022.12.01.22282980 doi: medRxiv preprint