Development of a Stress Assessment Scale for Pregnant Women During COVID-19 Pandemic

Ⅰ. Introduction

Ⅱ. Method

Ⅲ. Results

3-3 Construct Validity

1) Exploratory Factor Analysis

When KMO and Bartlett’s test of sphericity were analyzed, KMO was .90 and Bartlett’s χ²=4921.5 (df=378), showing that the data was suitable for factor analysis with a significance level of p<.001 (Table 1).

Table 1.

KMO and Bartlett’s test(N=330)

Principal axis factoring and promax rotation were used. Factors with an eigenvalue) ≥1, and items with factor loading ≥.5 were selected. As regards the 28 items, the analysis was repeated after omitting those with a communality of <.5 in factor analysis (item 1, 4, 6, 7, 10, 11, 12, 15, 16, 19, and 28) (Table 5).

When the analysis was repeated using the remaining 17 items, item 13 and 14 showed a factor loading <.5; after removing these items, there were a total of 15 item and five factors.

Factor 1 showed an eigenvalue of 7.04 and explained variance of 41.4%, while Factor 2 showed an eigenvalue of 1.78 and explained variance of 10.5%, and Factor 3 showed an eigenvalue of 1.43, and explained variance of 8.4%; Factor 4 exhibited an eigenvalue of 1.15 and explained variance of 6.8%, and Factor 5 showed an eigenvalue of 1.02 and explained variance of 6.0%, meaning that the total explained variance of the five factors was 73.1% (Table 6).

Factor 1 consisted of five items on stress due to antenatal management during the COVID-19 pandemic. The factor’s name was “stress due to antenatal management.” Factor 2 consisted of three items related to uncertainty and anxiety about the possibility of becoming infected with COVID-19, whether the number of infections would increase, and how much longer the outbreak would last. The factor’s name was “stress due to uncertainty.” Factor 3 consisted of three items on stress related to isolation, and restrictions on social gatherings and daily living. The factor’s name was “stress due to social restrictions.” Factor 4 consisted of two items on stress received from people in one’s surrounding environment. This factor was termed “stress due to relationships.” Factor 5 consisted of two items on stress related to COVID-19 infection control and quarantine measures. This factor was named “stress due to infection control.”

2) Criterion Validity

For criterion validity, we examined the correlation with K-PREPS. The total scores for each scale showed a significant correlation (r=.595, p<.001), but when we analyzed the correlations by factor, Factor 5 exhibited no correlation (Table 2).

Table 2.

Correlation between somatopsychological risk and K_PREPS(N=330)

3) Group Comparisons

We used a t-test to analyze the differences between the preterm birth and full-term birth groups. We found that stress was significantly higher in the preterm birth group (t=2.28, p=.023) (Table 3).

Table 3.

Differences in stress depending on pregnancy outcome(N=330)

4) Reliability Testing

When we tested reliability to analyze the internal consistency of the scale, Cronbach’s alpha was .896. The Cronbach’s alpha value for each factor was .884 for factor 1, .852 for factor 2, .863 for factor 3, .937 for factor 4, and .712 for factor 5. The 15 questions were divided into even and odd numbers, the Pearson correlation coefficient between the questions was calculated, and the reliability of the split-half test was tested using the Spearman-Brown formula. As a result, the reliability was confirmed to be .912 (p<.001).

Table 4.

General characteristics, obstetric characteristics and infectious disease-related matters of participants(N=330)

Ⅳ. Discussion

Stress during pregnancy has negative effects on the health of the mother[16]-[18]. In particular, novel viruses such as COVID-19 have more negative effects on pregnancy outcomes[4]. The purpose of this study was to develop a scale that could measure physical, psychological, and social stress levels in pregnant women during an infectious disease outbreak such as COVID-19.

Table 5.

Communalities(N=330)

We analyzed the construct validity and criterion validity of the stress measurement scale for pregnant women developed in this study using factor analysis. In terms of construct validity, all questionnaire showed a factor loading with their related factor of ≥.5, and with other factors of <.3. The cumulative variance explained for stress was 73.1%, showing strong explanatory power.

To test criterion validity, we analyzed the correlation with K-PREPS. We found that the total scores of the two scales exhibited a statistically significant correlation (r=.595, p<.001), but in the analysis by factor, Factor 5 did not show any correlation. When we tested internal consistency, we found that Cronbach’s alpha was .896. For the scale developed in this study, we identified five factors consisting of 15 items. The individual factors were named “stress due to antenatal management,” “stress due to uncertainty,” “stress due to social restrictions,” “stress due to relationships,” and “stress due to infection control.”

Table 6.

Factor analysis(N=330)

The existing Pandemic-related Pregnancy Stress Scale (PREPS) contains 15 items divided into three factors: perinatal infection stress, preparedness stress, and positive appraisal[1]. The PREPS has been validated and is being used in the US, Europe, and several countries across Asia.

However, the scale was developed in the early stages of the outbreak, before the declaration of a global pandemic, and so it may not be representative of the stress experienced during the whole pandemic[26]. In 2023, Kim and Heo adapted PREPS into a Korean version (K-PREPS). Compared to the original PREPS, K-PREPS consists of seven items and two factors, with the positive appraisal factor having been removed[22]. The categories in this scale are thought to be too small and simple to measure pandemic-related stress in pregnant women. By comparison, the scale developed in our study included factors not only for infection-related stress and antenatal stress, but also for stress due to uncertainty, stress due to social restrictions, and stress due to relationships. This shows that anxiety regarding infection, depression, and fear presented as stress due to uncertainty about information, and that excessive interest and worrying from family members and other acquaintances also acted as a source of stress. Moreover, social restrictions and infection control due to stronger quarantine measures were found to be an additional stressor.

Below, we consider each factor in more detail. Factor 1 consisted of items relating to “stress due to antenatal management,” demonstrating that the participants had concerns about antenatal management, including “worrying that antenatal management might not be consistent, worrying that they might not be able to receive antenatal care, and worrying about the lack of antenatal management guidelines.” Moreover, the question regarding “the lack of routes of communication relating to antenatal management during the pandemic” shows that there were very insufficient and limited routes of communication available. The increased stress experienced by pregnant women during the pandemic is also related to changes in quarantine guidelines during the pandemic, causing discomfort due to antenatal care appointments to be cancelled or rescheduled, a shortage of antenatal education, and restrictions on partners’ involvement in antenatal management[12],[28],[29]. In the existing PREPS instrument, items related to antenatal stress included birth-related stresses, such as worrying about being separated from their child after delivery or that their partner would not be able to be present, as well as worrying about not being able to receive antenatal care[1]. This is somewhat consistent with the items on antenatal management-related stress in our study. Providing good quality antenatal care during the COVID-19 pandemic was extremely important for the happiness of both the mother and the fetus[28]. In the future, in the event of a novel infectious disease outbreak such as the COVID-19 pandemic, since there is a tendency for quarantine and control guidelines to be strengthened, and for government quarantine guidelines to continually change depending on the situation, there is a very high risk of antenatal management-related stress in pregnant women. As such, it will be necessary to make efforts to improve the quality of antenatal management and education programs, and to reinforce antenatal management support systems at the national policy level, in order to guarantee healthy pregnancy and childbirth even in a pandemic.

Factor 2 was “stress due to uncertainty.” This included negative emotions such as anxiety, depression, and fear due to inaccurate information during the COVID-19 pandemic[14],[28],[29],[31]. The PREPS did not have a separate category for stress due to uncertainty, and negative emotions were included in items about infection-related stress and preparedness stress[1]. When we consider the cause of negative emotions, our study showed that they are related to uncertainty. Thus, during a pandemic, lack of infection-related knowledge, and the spread of unconfirmed COVID-19-related information and social media, can be identified as factors causing psychological instability in pregnant women[31]. Psychological instability is a negative emotional response, and anxiety, depression, fear, and worrying act as stress factors in pregnant women[14],[16]-[18],[28]-[30],[32]. Therefore, in order to provide interventions to combat the psychological instability experienced by pregnant women during the pandemic, we believe it will be necessary to develop strategies for coping with uncertainty. In order to cope with uncertainty during an event such as the COVID-19 pandemic, the most important factor is the provision of reliable information via healthcare service providers, public health institutions, and healthcare-related websites. In addition, it is essential to always keep pregnancy- and COVID-19-related guidelines for pregnant women up to date.

Factor 3 was social stress. During a pandemic, pregnant women experience stress due to social restrictions and changes in their social support systems[14],[28],[29],[31]. As a result of strengthened quarantine rules, daily living and social gatherings are restricted. In addition, confirmed patients are isolated at home, leading to controlled daily lives. These strong social restrictions lead to changes in existing social support systems[28]. The PREPS did not include items on stress due to social restrictions[1]. This difference appears to be due to the time of development of the PREPS, as well as cultural differences. With the spread of infectious disease, as well as increasing levels of control, South Korea implemented a “vaccine pass” system, leading to stronger social restrictions, which are thought to have acted as an even greater stressor for pregnant women, who are vulnerable to infection. Managing stress due to these social restrictions is crucial for the happiness of the mother and the optimal development of the fetus. Since public health guidelines are continually changing during a pandemic, it is essential to develop graded programs that can help manage psychological stress due to social restrictions.

Factor 4 was stress due to relationships. Worrying by family and other acquaintances caused a sense of burden in pregnant women. Other studies have also reported that excessive worrying by family and acquaintances was a source of burden that caused stress in pregnant women during the COVID-19 pandemic[29]. Conversely, however, the PREPS does not include items related to this theme[1], suggesting that the aforementioned is the outcome of cultural differences and different social perspectives of pregnant women. Pregnancy is a major event affecting the whole family, and so interest and worrying about the mother are natural phenomena, even when there is no pandemic. In the unique circumstances of a pandemic, people are even more concerned about the mother due to uncertainty regarding maternal infection and the health of the fetus, but the expression of these worries acts as a major source of burden for pregnant women[12],[29]. As such, it will be important to provide education about coping methods for the family of pregnant women.

Factor 5 was stress due to infection control, and consisted of items regarding pregnant women experiencing discomfort due to pandemic-related quarantine rules, and fatigue due to implementing disinfection and infection control practices. Although existing scales included infection-related stress, there was no separate category for stress due to infection control. Due to governmental infection control guidelines, the participants at the time of this study experienced fatigue related to adhering to the recommended guidelines, such as wearing masks, washing hands, and maintaining physical distance. By choosing specific strategies that prioritize the physical and mental well-being of everyone, it may be possible to reduce stress in pregnant women due to infection control during pandemic such as COVID-19.

Pregnant women’s stress during the COVID-19 pandemic had an effect on preterm birth[4]. To see whether we could also observe this effect, we separated participants into a preterm birth group and a full-term birth group and analyzed differences between the groups. We found that stress was significantly higher in the preterm birth group (t=2.28, p=.023). This clearly demonstrates the importance of stress management for pregnant women to prevent preterm births during an infectious disease pandemic. Considering the possibility that antenatal management may be neglected due to fear of infection and quarantine rules[12],[28],[29], it will be important to develop antenatal management and remote education programs via remote support.

The significance of this study lies in its ability to comprehensively measure the stress experienced by pregnant women in comparison to the PREPS tool developed in the early stages of infectious diseases. Furthermore, it addresses the limitations of the Korean version of PREPS by providing a tool that can measure the psychological, social, and physical stress experienced by pregnant women, thereby preparing for future pandemic or other forms of crises.

However, there were limitations in recruiting participants for the development of the measurement tool at the point when the COVID-19 pandemic had ended, as the sample consisted of pregnant women who were pregnant during the pandemic. It should be noted that generalizing the findings to all pregnant women in Korea is restricted as the participants were recruited from a subset of the pregnant population in Korea.

Ⅴ. Conclusion and Recommendations

The scale developed in this study can be used to measure physical, psychological, and social stress levels in pregnant women during the COVID-19 pandemic. We anticipate that this scale could be useful for stress management in pregnant women, who are a vulnerable group, in the event of another novel infectious disease outbreak.

Based on our findings, we make the following proposals for follow-up research to improve the level of stress management for pregnant women in the face of novel infectious diseases, such as the COVID-19 pandemic. First, it will be important to study the development of an application to allow pregnant women to easily measure their own stress levels during a novel infectious disease outbreak. Second, it will be important to perform replication studies developing instruments that can measure stress in pregnant women by investigating stress levels and characteristics depending on the form of public health response to novel infectious diseases. Third, there is a need to conduct research to construct integrative support systems for pregnant women during a novel infectious disease outbreak, and to develop programs to help pregnant women cope with stress. Lastly, this study is a survey of data based on current memories of past experiences, and temporal differences and distortions of memory may affect the research results. Therefore, in the event of an infectious disease such as COVID-19, the tool developed in this study can be repeated in the future. Research is needed.

Acknowledgments

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (2022R1G1A100987912).

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