Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 5 Issue: 5

Depression, Anxiety and Stress during Pregnancy

Quaresma C1*, Silva C2, Forjaz Secca M1,3, Goyri O’Neill J1,4 and Branco J4,5
1Laboratório de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologias, Universidade Nova de Lisboa, 2829-516 Monte da Caparica, Portugal
2Escola Superior de Saúde do Alcoitão, 2649-506 Alcabideche, Portugal
3Ressonância Magnética – Caselas, 1400-045 Lisboa, Portugal
4Nova Medical School, Universidade Nova de Lisboa, Campo dos Mártires da Pátria, 1169-056 Lisboa Portugal
5Maternidade Drº Alfredo da Costa, 1069-089 Lisboa, Portugal
Corresponding author : Claudia Quaresma
(LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologias, Universidade Nova de Lisboa, 2829-516 Monte da Caparica, Portugal
Tel: +351 212948576
E-mail: [email protected]
Received: July 20, 2016 Accepted: July 07, 2016 Published: July 12, 2016
Citation: Quaresma C, Silva C, Forjaz Secca M, Goyri O’Neill J, Branco J (2016) Depression, Anxiety and Stress during Pregnancy. J Womens Health,Issues Care 5:5. doi:10.4172/2325-9795.1000247


Objective: The purpose of the present study is to quantitatively evaluate psychological factors (depression, anxiety and stress) on four different moments of pregnancy.
Study design: The presence of depressive, anxiety and stress symptoms and their severity were evaluated at 12, 20, 32 and 37 weeks of gestation, in 47 pregnant women aged between 20 and 39 years, using the Depression Anxiety and Stress Scales. Factor analysis was performed on the full 42 items of the scales. We used the Wilcoxon test to compare the different moments of evaluation.
Results: scores higher than the normal level were found for 19.1% (at 12 weeks), 12.8% (at 20 weeks), 21.3% (at 32 weeks) and 17% (at 37 weeks) of women in the case of depression, for 21.3% (at 12 weeks), 29.8% (at 20 weeks), 48.9% (at 32 and 37 weeks), of women in the case of anxiety, and 27.7%. (at 12 weeks), 29.8% (at 20 weeks), 36.2% (at 32 and 37 weeks) of women in case of stress.
Conclusion: We found out that stress and anxiety increased during pregnancy while depressions decreased at 20 weeks of gestation and increased again during the 3rd trimester.

Keywords: Pregnancy; Depression; Anxiety; Stress


Pregnancy; Depression; Anxiety; Stress


Over the past few years there have been several studies that showed the existence of psychological disturbances during pregnancy [1-9]. Although information on risk factors for antenatal anxiety and depression is available in literature [10], most studies focus only on a particular stage of pregnancy. A longitudinal analysis of the risk of depression, anxiety and stress across different stages of pregnancy is needed to identify the levels of these factors on the same moment in pregnant women, because it’s relevant for developing effective prevention and early intervention strategies [9].
Depression is one of the most common complications in pregnancy [1] and it’s estimated that 20% of women experience symptoms of depression during pregnancy [11].
At present, several professional organizations recommend routine screening for ante-partum depression [1]. In fact, the American Congress of Obstetricians and Gynecologists (ACOG) recommend screening for depression on each trimester of pregnancy [1].
Lumley and Austin [12] refer that depression during the antenatal period is often associated with symptoms of anxiety. The experience of anxiety and depression during the course of pregnancy has been established to have important clinical implications for the expectant mother and infant [13,14]. Over time the relations between affective dimensions, anxiety and depression, have been considered important both from the theoretical point of view in the mental health and therefore constitute classical dimensions in psychology and psychopathology.
A significant relationship between depression during pregnancy and deleterious neonatal outcomes and adverse obstetric complications has been demonstrated [15]. Chung et al., [15] found that depression during late pregnancy was associated with a significant increase in the use of epidural analgesia, caesarean section, instrument deliveries and increased rates of admission of the neonate to the neonatal intensive care unit.
Effective and early screening for anxiety and depression symptomatology during pregnancy is therefore likely to be highly beneficial for identifying women at risk of postnatal depression. Psychological sequelae, including postnatal depression, have been established to be significantly predicted by levels of depression and anxiety during pregnancy [16]. This is a particularly important observation since approximately one in seven women develop postnatal depression shortly after delivery [17].
Anxiety has also been implicated in obstetric complications, in particular, excessive anxiety experienced during pregnancy has been found to be associated with an increased likelihood of a pre-term delivery and low birth weight [4-6,10,18,19]. Depression and anxiety were associated with increased risk of preeclampsia [9].
Existing estimates of the prevalence of depression, anxiety and stress during pregnancy vary widely. The objective of this study is to identify the simultaneous prevalence of depression, anxiety and stress during pregnancy by trimester, as detected by a validated screening instrument.

Materials and Methods

This study was approved by the Portuguese Ethics Committees of the Faculty of Medical Sciences of New University of Lisbon, of the Maternity Hospital Dr Alfredo da Costa and of the Regional Health Administration of Lisbon and Vale do Tejo.
All data was collected between October 2008 and December 2009 from a sample of pregnant women attending the obstetric services at the Health Center of Sete Rios, in Lisbon, Portugal. As the inclusion criteria for the application of Depression Anxiety Stress Scales (DASS) to the present study, we established that the pregnant women from the mentioned institution had to be in their 12th week of gestation, had no associated pathologies and had no history of psychological disorders.
The sample was composed by 47 pregnant women, aged between 20 and 39 years; 93,6% were Caucasian and 6,4% were African; 83% were married, 16,3% were single. In relation to academic qualifications we observed that 57,1% attended High School or less and 42,9% attended University.
Each pregnant woman was previously informed about the procedures and the objectives of the study, and signed an informed consent. We employed the Depression Anxiety and Stress Scales for evaluating the depression, anxiety and stress of pregnant women in four stages of pregnancy: 12, 20, 32 and 37 weeks of gestation in the same woman. No women received any physiological treatment throughout pregnancy.
Depression Anxiety Stress Scales (DASS)
The DASS [20] aim to assess a set of negative emotional symptoms related to depression, anxiety and stress. It has been validated for the Portuguese population performed by Pais-Ribeiro, Honrado and Leal [21]. Lovibond e Lovibond [20] characterize the DASS as follows aspects: depression over the loss of self-great affection and motivation, and is associated with the perception of low probability of achieving life goals; anxiety highlights the links between persistent state of anxiety and intense fear responses; stress is related to the excitation states and persistent tension, with low level of resistance to frustration and disappointment.
The DASS are a 42 item questionnaire that consists of three subscales (each with 14 items) designed to measure levels of anxiety, depression and stress. For each question there are four possible answers, presented in a Likert scale, where the subject must choose the one closer to their degree of concordance. The subjects evaluated the extent to which each symptom experienced during the last week best corresponded to a 4-point scale of severity / frequency (“did not apply anything to me”; “applied to me sometimes”; “applied to me often”; “applied to me most of the time”). Each response, from a minimum of 0 (did not apply to me to all) to a maximum of 3 (applied to me most of the time), adds to the total score. Factor analysis was performed on the full 42 items of the scales subdivided by the three previously mentioned subscales. The results of each scale being then the sum of the individual scores of each answer. The highest marks in each scale represent the most negative emotional symptoms. The levels of the scale are: normal, average, moderate, severe and very severe. We must stress the fact that the normal level is designated when the patient doesn’t have any pathology.
Statistical analysis
We used the Wilcoxon test to compare the four stages of pregnancy, considering four different combinations of two moments (m1 vs m2, m3 and m4, m2 vs m3 and m4, m3 vs. m4). This nonparametric test was applied because the response scale is of an ordinal qualitative type (Normal, Average, Moderate, Severe and Very Severe). The level of significance was 0.05.


The main results of the longitudinal study, which examined the psychological changes (depression, anxiety and stress) that occur during pregnancy, are shown in Tables 1 and 2 where the shadowed areas represent the most significant differences.
Table 1: Frequencies: Depression, Anxiety and Stress during the four moments of evaluation.
Table 2: Wilcoxon and Percentage of pregnant women who maintained worsened or improved levels of Depression, Anxiety and Stress during the four stages of pregnancy.
The Table 1 shows the frequencies of depression, anxiety and stress during the four moments of evaluation. For depression, 80.9% of women in the first trimester did have a normal depression level, while to 6.4% had values identified with a score of average depression, 6.4% had a depression characterized as moderate and 6.4% had a severe depression.
In the second stage of data collection (20 weeks of gestation) the percentage of women who had a depression level considered normal is 87.2%, while 10.6% of women had a level of depression considered average, and 2.1% had a depression identified as moderate. No women showed a level of depression considered severe and very severe.
As Table 1 shows, in the third trimester of pregnancy (32 and 37 weeks of gestation) the same number of pregnant women showed a depression considered severe (4.3%) and very severe (2.1%). It was found that at 32 and 37 weeks of gestation, 78.7% and 83.0% of women, respectively, did not had levels of depression higher than normal.
In addition, it was observed that at 32 weeks, 10.6% women had levels of depression considered moderate, while at 37 weeks the percentage of women with this level decreased to 8.5%.
So for Depression we can conclude that, at 20 weeks of gestation, a higher percentage of women experience a depression scores within the normal range while at 32 weeks of gestation a reduced number of women showed the same level of depression.
On the other hand, for anxiety, 78.7% of women in the first trimester had values for anxiety considered normal, while 8.5% had values identified with an average anxiety disorder, 8.5% had an anxiety disorder characterized as moderate, 2.1% had a severe anxiety and 2.1% had an anxiety considered very severe.
It can be seen in Table 1 that at 20 weeks of pregnancy 70.2% of women had levels of anxiety considered normal, but 6.4% had an anxiety disorder that is characterized as average. 10.6% of women during this gestational period had levels that are defined as moderate, 8.5% of females were considered to have severe anxiety and 4.3% were classified as very severe.
At 32 and 37 weeks of gestation the same number of women showed normal (51.1%), severe (8.5%) and very severe (10.6%) anxiety levels. However, the average and moderate levels of anxiety showed a different distribution: at 32 weeks 12.8% and 17.0% and at 37 weeks of gestation, 6.4% and 23 4%, respectively.
Regarding stress, 73.3% of women at 12 weeks of gestation were considered normal regarding stress, 12.8% were identified with average stress values, 8.5% were characterized with moderate stress and 2.1% had values recognized as severe stress.
We found that 70.2% of women at 20 weeks gestation had levels considered normal, but 14.9% had levels described as average, 12.8% had a stress rated as moderate and 2.1% as very severe. However, none of them had levels of stress considered severe.
For the 32 weeks we found that fewer women had levels of stress regarded as normal (63.8%) and levels of stress regarded as average stress levels (2.1%). 19.1% of women had a level of stress described as moderate, 12.8% of women had a score of stress considered severe and only 2.1% of the sample had a stress classified as very severe.
It was observed that at 37 weeks of gestation, as at 32 weeks, 63.8% of women showed values of stress within normal parameters. For 32 weeks of gestation, there was an increase in women with average (4.3%), severe (14.9%) and very severe (4.3%) stress levels. Considering the moderate level of stress there is a decrease in the percentage of women in that level (12.8%) when compared to the same situation at 32 weeks of gestation.
A large percentage of women (above 35%) show more anxiety and stress in the last stages of pregnancy (32 and 37 weeks) than what is considered normal, whereas the depression prevalence rates are lower and tend to range between 17% and 21, 30% over the four stages (Figure 1).
Figure 1: Percentage of pregnant women with higher than normal scores.
Table 1, shows the percentage of pregnant women who maintained, worsened or improved levels of Depression, Anxiety and Stress during the four stages of pregnancy
According to the Wilcoxon test a significant difference from the 20th week to the 32nd week was found, with a higher percentage of women suffering from greater levels of depression, anxiety and stress in the transition between these two stages (Table 2). We must to highlight the following aspects:
For depression
A greater percentage of women suffer from depression (21.30%) during the 3rd stage (32 weeks). The Wilcoxon test allowed us to verify the existence of significant differences between the various stages: by performing a comparative analysis of each stage with the stage that directly succeeds it, it was possible to note that: the differences between the first two stages are not significant; there is a significant difference for p ≤ 0.01, from the 2nd to the 3rd stage, in that 19% of the women’s condition worsened; the differences between the 3rd and 4th stages are not significant and the levels of depression in the majority of women remains the same.
For anxiety
A greater percentage of women suffer from anxiety (48.9%) during the 3rd and 4th stages (32 and 37 weeks). The Wilcoxon test revealed the lack of difference between the 12th and 20th week. However, the anxiety states of 38.3% of the women worsened, although no significant differences were registered between the 3rd and 4th stages.
For stress
Similarly, to what happens with anxiety, it’s during the 3rd and 4th stages that stress levels increase (36.2% of women with stress levels above normal). According to the Wilcoxon test, no significant differences were found between the 12th and 20th week and between the 32nd and 37th week. A significant difference was found between the 20th and 32nd week and it was noted that 34% of the women’s conditions worsened.


The aim of this longitudinal study was to examine the changes in depression, anxiety and stress that occur during pregnancy. For that purpose, the Depression Anxiety and Stress Scales were applied to each woman in four differences moments of pregnancy: 12, 20, 32 and 37 weeks of gestation.
For depression we found that the scores were higher than normal at: 12 weeks (19.2%); 20 weeks (12.7%); 32 weeks (21.3%); 37 weeks of gestation (17.0%). These results are consistent with those reporting that 20% of pregnant women suffer from antenatal depression [4]. However, they are different from the results that report that substantial, levels of depression happen especially during the second and third trimesters of pregnancy [22], as we observed that the lower values occur in the second trimester (20 weeks).
We verify also that the level of anxiety increases over the three trimesters of pregnancy. It was observed that at 12 weeks of gestation 21.2% of pregnant women had scores above normal, at 20 weeks of pregnancy 29.6% showed anxiety levels above normal and in the third trimester of pregnancy this percentage was 48.9%. These results were different from the study of the second-trimester, which found that 6.6% of pregnant women had antenatal anxiety disorders [3].
These results agree with what Burstein et al., [22] which refer that the anxiety becomes more obvious near delivery.
Contrary to what happened with depression, anxiety and stress is present in an increased percentage of pregnant women: 20.2% and 27.7% for anxiety and stress respectively, for 12 weeks gestation and 29.8% are well above normal in the second stage of evaluation in both anxiety and stress.
Through these results we can conclude that there is a higher percentage of pregnant women with scores above average on the items of anxiety and stress.
Antenatal anxiety was more prevalent than depression. The prevalence of antenatal anxiety was 36.3% on the first trimester, and the rate dropped to 32.3% on the second trimester but increased again to 35.8% on the third trimester. For antenatal depression, the prevalence was 22.1% on the first trimester [7].
Concerning anxiety and stress it was also observed that pregnant women show higher scores in the third trimester, with significant differences from the 1st and 2nd trimester. Regarding depression there is an increase in the number of pregnant women with scores above the normal, 21.3% at 32 weeks, while at 37 weeks that number decreased to 17%. We verify also that there are significant differences between the second and third trimesters, unlike the results obtained between the first and second trimesters.


Mental health problems in the antenatal period are much less recognized than those in the postpartum period. Our findings, however, showed that antenatal mental health problems are prevalent, with antenatal depression, anxiety and stress symptoms being even more prevalent in this period.
Our data shows that antenatal anxiety; depression and stress are not static but instead show a changing course during gestation. It was found that stress and anxiety increased during pregnancy while depressions decreased at 20 weeks of gestation and increased again during the 3rd trimester.
This study has provided new clinical information about the psychological changes during pregnancy, as it studied three very important aspects – stress, depression and anxiety - at the same time for four different moments in the same woman. This investigation can help to define intervention methodologies directed to pregnant women especially at a prevention level.


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