https://doi.org/10.53453/ms.2024.11.8
Associations between coping strategies employed by expectant
mothers and prenatal distress
Kamilė Andruškaitė
1
, Milda Kukulskienė
1
1
Department of Health Psychology, The Faculty of Public Health, Lithuanian University of Health Sciences,
Kaunas, Lithuania
Summary
Background. Pregnancy brings numerous anatomical, physiological, physical, psychological and social changes
that can influence distress symptoms in expectant mothers. Increased maternal distress during pregnancy may be
linked to coping strategies, partner and family support.
The aim of this study was to assess the associations between coping strategies employed by expectant mothers
and their distress experienced during pregnancy.
Methods. The sample consisted of female participants who voluntarily responded to the survey. The selection
criteria included were female gender, pregnancy, full age and Lithuanian mother tongue. A quantitative research
strategy was chosen. The survey included socio-demographic questions, the Prenatal Coping Inventory (NuPCI)
and the Tilburg Pregnancy Distress Scale.
Results. The planning-preparation coping strategy was the most frequently used coping strategy (p < 0.001),
compared with the avoidance and spiritual-positive coping strategies (planning-preparation subscale, 2.05 ± 0.58
points; spiritual-positive coping, 1.27 ± 0.79 points; and avoidance subscale, 1.32 ± 0.55 points). Overall, 42.6%
of the participants experienced distress, with the least distress felt when their partner was involved (82.2%).
Conclusions. 1. Statistically significant differences in the Prenatal Coping Inventory (NuPCI) between trimester,
singleton, and repeated pregnancies, and having or not having children were revealed. 2. Almost half of the
participants (42.6%) experienced elevated levels of distress. 3. No significant correlations were found between
the type of spiritual-positive coping used by expectant mothers and levels of distress, partner involvement and
negative affect.
Keywords: distress; coping; pregnancy; prenatal distress.
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Medical Sciences 2024 Vol. 12 (5), p. 71-81, https://doi.org/10.53453/ms.2024.11.8
71
1. Introduction
Pregnancy is a time of numerous anatomical and
physiological changes. Expectant women must not
only nurture and accommodate the foetus but also
adapt to new bodily changes [1]. Pregnant women
experience both physical and psychological, as well
as social changes in their lives, and these changes
can influence the emergence of distress symptoms
[2]. In a study conducted by Yilmaz and other
researchers (2021), factors influencing distress
during the prenatal period were described, including
low social and economic status, low educational
attainment, feelings of loneliness, and employment
status (unemployment had a greater impact on
higher distress levels) [3]. It is emphasized that
increased maternal distress symptoms during
pregnancy may be related to coping strategies
employed, partner and family support, as well as
economic and social circumstances [4].
Therefore, expectant mothers face various
challenges that may be associated with heightened
anxiety, stress, and depression symptoms. Hence, it
is crucial to understand how expectant women cope
with these difficulties, what coping strategies they
employ, and how the strategies used relate to
experienced distress [5, 6].
This topic is relevant and significant because
expectant women are prone to experiencing high
levels of stress, anxiety, and symptoms related to
depression due to hormonal changes, bodily
changes, and emotional difficulties associated with
pregnancy [7, 8]. Additionally, the well-being of
expectant mothers is important to society, as healthy
and happy mothers are essential factors in ensuring
the health and happiness of future generations [9].
Therefore, it can be argued that understanding
distress experienced by expectant mothers and their
coping methods can be valuable while improving the
psychological well-being of mothers giving birth
and those who have recently given birth, reducing
stress levels, anxiety, and enhancing infant
development [10, 11]. Consequently, the results of
this research can help better understand the
psychological health of expectant mothers, assist
their loved ones and medical personnel in better
responding to the needs of expectant mothers, and
provide them with tools to cope with stress and
overcome challenges, thereby contributing to a
positive pregnancy experience.
Objective of this Study: to assess the associations
between coping strategies employed by expectant
mothers and distress experienced during pregnancy.
Research Objectives:
1. Analyse the coping strategies employed by
expectant mothers.
2. Determine the level of distress experienced during
pregnancy.
3. Evaluate the associations between coping
strategies employed during pregnancy and
experienced distress.
2. Research methods
2.1. Procedure and Sample
In February 2023, the research topic, objective, and
tasks were formulated, research design decisions
were made, and data collection tools were identified.
After obtaining the necessary permissions, the
Prenatal Coping Inventory (NuPCI) one other scale
were translated from English to Lithuanian through
a double translation process. Later on, approval to
conduct the study was obtained from the Bioethics
Centre of the Lithuanian University of Health
Sciences, with the permit number BEC-SP(B)-83. A
copy of the bioethics approval is provided in the
appendix of the study (see Appendix 1).
On March 25, an online survey was created using the
"Forms office" platform. Starting from March 26,
the prepared electronic survey was shared on social
media platforms, specifically "Facebook" and
"Instagram." Personal messages were sent via
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Instagram to several profiles related to parenthood
and pregnancy. On April 19 and 20, a few additional
permissions were obtained to share the research
survey, but since the required sample size had
already been reached, the data collection was
discontinued considering the scope of the study and
the participants' resources. The online survey
allowed participants to respond only once from one
device. In the survey, ethical information was
provided, and participants were informed about the
confidentiality of the study. The online survey did
not collect personally identifiable information such
as name/surname and other personal details,
ensuring anonymity. The collected research data is
stored on the researcher's computer in a password-
protected folder. In total, 129 women's responses
were collected through the online survey.
The research sample consisted of 129 pregnant
women. The following selection criteria were
applied when collecting the research data: adult
pregnant women; native speakers of the Lithuanian
language.
2.2. Research Instruments
A quantitative research strategy was chosen for this
study. The survey included socio-demographic
questions and utilized two scales: the Prenatal
Coping Inventory (NuPCI) and the Tilburg
Pregnancy Distress Scale.
Socio-demographic questions: Participants were
asked to provide their age, pregnancy trimester,
whether it was their first pregnancy, whether they
had previous children, place of residence (choosing
from 3 options: city centre, urban area, small town
or village), and educational level. All questions had
predefined response options (see Appendix 2).
The Tilburg Pregnancy Distress Scale was used in
this study to assess the expression of distress
symptoms among pregnant women. The scale was
developed by Pop et al. (2011). Prior to this study,
the scale had not been translated into the Lithuanian
language. Therefore, on February 27, a double
translation was conducted independently by the
project supervisor, Milda Kukulskienė, PhD. and the
researcher, Kamilė Andruškaitė, who later discussed
the translation discrepancies. This scale consists of
16 items (e.g., "I feel that my partner and I are
enjoying the pregnancy together," "I worry about
giving birth," "I worry about our financial situation
after the baby is born," etc.). The items are rated on
a 4-point Likert scale. The ratings reflect how the
pregnant women felt over the past seven days.
Participants could choose from four options ("very
often," "quite often," "sometimes," "rarely or
never"). The questions in this scale are related to
how the participants perceive their pregnancy. There
was no need to obtain permission to use the scale in
this study since the authors encourage its free use in
research and translation into different foreign
languages (see Appendix 2).
The internal reliability of the entire Tilburg
Pregnancy Distress Scale, consisting of 16
statements, was assessed using Cronbach's alpha and
yielded a value of 0.80. The negative affect subscale
had a Cronbach's alpha of 0.80, and the partner
involvement subscale had a Cronbach's alpha of
0.82. The internal consistency of this questionnaire,
as measured by Cronbach's alpha coefficient, is
high.
Table 1. Internal consistency of the Tilburg Pregnancy Distress Scale and its subscales (N = 129).
SCALE
CRONBACH'S ALPHA
NUMBER OF STATEMENTS
Distress total score
0.80
16
Negative affect
0.80
11
Partner engagement
0.82
5
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The Prenatal Coping Inventory (NuPCI) is a scale
designed to assess how often pregnant women have
used various coping strategies in the past month to
manage the stress and challenges associated with
pregnancy. The authors of this scale are Hamilton
and Lobel (2008). Similarly to the previous scale,
the instrument has not been translated into the
Lithuanian language. Therefore, in February 2023, a
double translation was performed in collaboration
with the project supervisor, Milda Kukulskienė,
PhD. This scale consists of 42 items (e.g., "Did you
imagine what your childbirth would be like?" "Did
you spend time together or talk with someone who
recently gave birth?" "Did you wish the childbirth
was already over?") and five response options:
"never", "almost never", "sometimes", "fairly
often", "very often". Additionally, there were
several open-ended questions in this questionnaire
that did not require a mandatory response.
Permission to use this instrument was obtained via
email on February 23, 2023 (see Appendix 2).
The means of all the scales and subscales subscales
are equal to or greater than 0.70).
Table 2. Prenatal Coping Inventory (NuPCI) and Subscale Cronbach's Alpha Coefficients (N = 129).
2.3. Study Material and Participants
The study employed convenience sampling, and
voluntarily participating respondents were included
in the research. Evaluation standards for the
participants were as follows: adult pregnant women
whose native language is Lithuanian. The
participants had the opportunity to withdraw from
the study at any time. An anonymous online survey
was shared in a "Facebook" group and on another
social media platform, "Instagram." The survey was
completed by 129 pregnant women, and all
responses were included in the analysis. The
majority of the women who participated in the study
resided in urban areas (77 %), and most of them had
obtained a higher education degree (81 %). Nearly
half of the participants were between 26 and 30
years old (47 %), and 52 % of them were in the third
trimester of pregnancy. Social and demographic
characteristics of the sample are presented in
Table 1.
Table 3. Distribution of Participants by Sociodemographic Indicators.
Indicator
Response options
Absolute count (n)
Percentage distribution (%)
Pregnancy trimester
I
21
16
II
41
32
III
67
52
First pregnancy
Yes
61
47
No
68
53
SCALE
CRONBACH'S ALPHA
NUMBER OF STATEMENTS
NuPCI Avoidance
0.70
11
NuPCI Planning-Preparation
0.79
14
NuPCI Spiritual-Positive Coping
0.76
6
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Previously had
children
Yes
53
41
No
76
59
Place of residence
Metropolitan
(Vilnius; Kaunas;
Klaipėda; Šiauliai)
99
77
City
17
13
Town or village
13
10
Education
Primary
-
-
Secondary
9
7
Higher secondary
15
12
Higher education
105
81
Age
up to 25 years
14
11
26-30 years
61
47
31-35 years
42
33
over 36 years
12
9
2.4. Data Analysis Methods
Upon completion of data collection, data analysis
was initiated. Participants' responses were processed
and transferred to Microsoft Excel 2023 for data
entry, while the statistical software package IBM
SPSS 29.0.0.0 was used for data analysis. Microsoft
Excel 2023 was utilized for initial data analysis and
table creation. The primary survey data was entered
into this program. In the descriptive statistical data
analysis phase, absolute counts (N) and percentages
were calculated for normally distributed variables,
and tables were generated. For interval variables,
mean and standard deviation were reported.
Statistical methods were selected after examining
the distribution of data according to the normal
distribution. Given the relatively large sample size
(129 participants), normality was assessed based on
skewness and kurtosis coefficients as well as
histogram examinations. The distribution of interval
variables was assessed using the Shapiro-Wilk test,
and if the skewness and kurtosis were within the
range of -2 to +2, it was considered to satisfy the
assumption of normality [12]. Independent samples
t-test was employed for comparing two groups of
interval variables, while one-way ANOVA was used
for comparisons involving more than two groups.
Paired samples t-test was employed for dependent
samples within the same group. Chi-square test was
used for comparing the frequencies of categorical
variables, and Fisher's exact test was used for small
sample sizes. To compare proportions between two
groups, z-test was employed. Pearson's correlation
coefficient (r) was utilized to assess relationships
between different variables. The significance level
for statistical hypotheses was set at p < 0.05 for
statistically significant and p > 0.05 for not
statistically significant results.
3. Results
3.1. Coping Strategies Used by Expectant
Women
The first objective of the study was to investigate the
coping strategies used by expectant women. To
analyse the application of coping strategies among
expectant women, associations with socio-
demographic data were evaluated, and questions
from the Prenatal Coping Inventory (NuPCI) were
examined. These questions aimed to assess how
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frequently participants utilized various coping
strategies in the past month to manage the stress
associated with pregnancy and cope with emerging
challenges.
3.1.1. Expression of Coping Strategies Used by
Expectant Women
In the overall group of expectant women, there was
a statistically significant difference (p < 0.001) in the
most frequently used coping strategy, which was
planning-preparation, compared to avoidance and
spiritual positive coping strategies (mean score of
planning-preparation subscale: 2.05 ± 0.58, spiritual
positive coping: 1.27 ± 0.79, avoidance subscale:
1.32 ± 0.55). The indicators are presented in the
figure 1.
3.2. Level of Distress Experienced by Women
During Pregnancy
The second objective of the study was to determine
the level of distress experienced by women during
pregnancy. To assess the level of distress, the study
focused on questions regarding self-perceived well-
being over the past seven days, using the Tilburg
Pregnancy Distress Scale, and evaluated the
associations with socio-demographic indicators.
From the study results, the distress level, or its
absence among expectant women in each subscale is
presented as a percentage. It was considered that if
the overall scale score was equal to or higher than
17, distress was present. A score of 12 or higher in
the negative affect subscale was considered
indicative of unpleasant feelings, while a score
higher than 7 in the partner support subscale
indicated that the pregnant woman receives partner
support [13]. A total of 42.6 % of participating
expectant women felt distress, with the least distress
experienced by pregnant women when there was
partner involvement (82.2%). The distribution of
women according to distress level during pregnancy
can be seen in Figure 2.
Figure 1. Evaluation of coping strategies in the overall group of expectant women using linear ANOVA criterion.
2.05
1.32
1.27
0
1
2
3
4
Grades
Planning-preparation Avoidance Spiritual positive coping
***
***
*** p < 0,001
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Figure 2. Distribution of Pregnant Women according to the Tilburg Pregnancy Distress Scale, univariate
analysis.
3.2.1. Association between Distress Level and
Socio-demographic Characteristics
The manifestation of distress related to partner
involvement was investigated based on socio-
demographic indicators. Statistically significant
results were found in both groups of women,
including those experiencing their first pregnancy
and those who were already pregnant for more than
once (p = 0.007). The presence of children and
partner involvement were also statistically
significant. Women who had previously given birth
and felt romantic partner involvement experienced
no distress (52.8%), while only 21.7% of pregnant
women who had previously given birth reported
experiencing distress. However, women who had
not previously given birth and had an involved
partner experienced a lower level of distress
(65.1 %). Age was also statistically significant (p =
0.004). Women aged 26 to 30 years reported no
distress in relation to partner involvement (53.8 %),
while women in the 31-35 age group, whose
romantic partners were involved, experienced
distress (60.9 %). The data are presented in Table 4.
3.3. Associations Between Coping Strategies
Applied During Pregnancy and the
Manifestation of Experienced Distress
The third objective of the research aimed to reveal
the associations between coping strategies applied
during pregnancy and the manifestation of
experienced distress. Pearson's correlation method
was chosen to analyse these results. The research
findings revealed that a higher level of distress (r =
0.53; p < 0.001), as well as negative affect (r = 0.37;
p < 0.001) and distress due to partner non-
involvement (r = 0.45; p < 0.001), were associated
with more frequent avoidance. The correlation
coefficients indicated weak to moderate
associations. Furthermore, the study data indicated
that higher levels of negative affect were associated
with more frequent proactive coping (r = 0.30; p <
0.001), while a higher level of distress due to partner
non-involvement was associated with less frequent
proactive coping (r = -0.24; p = 0.006). The
correlation coefficients indicated weak associations.
Refer to Table 5.
57.4
63.6
82.2
42.6
36.4
17.8
0
10
20
30
40
50
60
70
80
90
100
Distress total score Negative affect Partner engagement
is not present is present
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Table 4. Level of distress related to partner involvement manifested by socio-demographic indicators. Student's
t-test and ANOVA were used.
Indicators
Partner engagement
p
Was not present
Distress was
present
n=106
n=23
Pregnancy trimester, n (%):
0.608
I
19 (17.9 %)
2 (8.7 %)
0.280
II
33 (31.1 %)
8 (34.8 %)
0.731
III
54 (50.9 %)
13 (56.5 %)
0.627
Is this your first pregnancy, n (%):
0.007
Yes
56 (52.8 %)
5 (21.7 %)
No
50 (47.2 %)
18 (78.3 %)
Do you have any previous children, n (%):
0.002
Yes
37 (34.9 %)
16 (69.6 %)
No
69 (65.1 %)
7 (30.4 %)
Age, n (%):
0.004
≤25 years
11 (10.4 %)
3 (13.0 %)
0.718
26-30 years
57 (53.8 %)
4 (17.4 %)
0.002
31-35 years
28 (26.4 %)
14 (60.9 %)
0.001
>35 years
10 (9.4 %)
2 (8.7 %)
0.917
Place of residence, n (%):
0.515
Town or village
9 (8.5 %)
3 (13.0 %)
0.502
City
14 (13.2 %)
4 (17.4 %)
0.600
Metropolitan
83 (78.3 %)
16 (69.6 %)
0.373
Education, n (%):
0.309
Lower than higer
18 (17.0 %)
6 (26.1 %)
University degree
88 (83.0 %)
17 (73.9 %)
Table 5. Associations between experienced distress and coping strategies used during pregnancy, Pearson's
correlation.
Strategies
Negative Affect
Partner Involvement
Distress
r
p
r
p
r
p
Avoidance
0.37
< 0.001
0.45
< 0.001
0.53
< 0.001
Spiritual positive coping
0.14
0.105
-0.07
0.403
0.06
0.479
Preparation-planning
0.30
< 0.001
-0.24
0.006
0.13
0.159
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3.4 Strengths and limitations of the study
Strengths of the study: this study is the first in
Lithuania to analyse the relationship between coping
strategies and distress in pregnant women. It is also
the first study to address a topic that is relevant in
today's society and has not been explored much. It
should be mentioned that 129 pregnant women
volunteered to participate in the study and most of
the factors studied were statistically significantly
related to both distress levels and coping strategies.
This suggests that there is a correlation between
coping mechanisms and distress levels. The results
of the study provide a basis for further research.
Limitations of the study: Although the study has a
high relevance, there are limitations. One of the
limitations of this
thesis would be the lack of socio-demographic
questions, as the participants were not asked about
their marital status and financial situation, which are
presumably also important extraneous factors that
may be associated with psychological well-being
and distress levels. As participation in the survey
was voluntary, the sample is not representative, as
pregnant women who have had difficult experiences
or mental health problems may not have filled in the
questionnaire.
4. Conclusions
1. Statistically significant differences in the Prenatal
Coping Inventory (NuPCI) were observed between
trimester, singleton and repeat pregnancies, and
having or not having had a child previously. Among
pregnant women), the most frequently used coping
strategy was planning-preparation compared with
avoidance and spiritual coping strategies.
2. Analysis of the results of the Tilburg Pregnancy
Distress Scale shows that the pregnant women in the
study showed an increase in distress levels. Almost
half of the participants had elevated levels of
distress. Women aged 35 years and over were more
likely to experience distress.
3. The use of coping strategies is significantly
associated with the experience of distress among
pregnant women. No significant associations were
found between the use of spiritual-positive coping
strategies and the level of distress, partner
involvement and negative affect in pregnant women.
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