Indian Journal of Public Health

: 2019  |  Volume : 63  |  Issue : 3  |  Page : 209--214

Development of perceived prenatal maternal stress scale

P Sreeja Gangadharan1, S P K. Jena2,  
1 Assistant Professor, School of Business Studies and Social Sciences, CHRIST (Deemed to be University), Bengaluru, Karnataka; Research Scholar, Department of Psychology, University of Delhi, New Delhi, India
2 Professor (University of Delhi), Department of Psychology, New Delhi, India

Correspondence Address:
S P K. Jena
School of Business Studies and Social Sciences, CHRIST (Deemed to be University), Bengaluru - 560 076, Karnataka


Background: Pregnancy is a state, which is often associated with extreme joy and happiness. Women undergo a number of physiological and psychological changes during pregnancy, which are often stressful if aligned with other adverse life events, compromising their health and well-being. However, there exists no comprehensive psychological instruments for measuring this stress. Objectives: The study was conducted to develop a multidimensional scale to assess prenatal maternal stress (PNMS) comprehensively. Methods: The initial phase of the study focuses on developing items and assessing the content validity of these items. The second phase focuses on pilot-testing and field-testing the newly developed perceived PNMS scale (PPNMSS) among 356 pregnant women belonging to different parity and trimester from November 2015 to October 2016. Results: The underlying factor structure of the 28-item PPNMSS had explored using exploratory factor analysis. The final scale is retained with 15 items having considerable item loading under four major factors as follows: perceived social support, pregnancy-specific concerns, intimate partner relations, and financial concerns. Reliability of each of these dimensions was assessed using Cronbach's alpha. Convergent and divergent validity of the scale was assessed by correlating the scores with perceived stress scale and the World Health Organization (five) well-being index (1998 version). Conclusions: As a comprehensive scale, PPNMSS is efficient to measure PNMS, which facilitates an early detection of stress and depression among pregnant women and timely intervention by health care professionals.

How to cite this article:
Gangadharan P S, Jena S P. Development of perceived prenatal maternal stress scale.Indian J Public Health 2019;63:209-214

How to cite this URL:
Gangadharan P S, Jena S P. Development of perceived prenatal maternal stress scale. Indian J Public Health [serial online] 2019 [cited 2020 Aug 8 ];63:209-214
Available from:

Full Text


Emotional response to stress during pregnancy is alternatively labeled in the literature as pregnancy-specific distress, worry, anxiety, or stress and these are the important components of prenatal maternal stress (PNMS).[1] Over the past decades, it has been well documented that PNMS is an intrauterine environmental risk for adverse birth outcomes such as preterm birth, babies with low birthweight,[2] high morbidity and mortality among newborns,[1],[3] and postnatal depression among women.[4] In addition, PNMS is associated with unplanned cesarean delivery and incidences of complications during labor and delivery.[5] The biopsychosocial approach linking pregnancy-specific events to birth outcomes and fetal programming hypothesis suggesting programming effect of PNMS on fetus[6] had also gained much attention of the researchers over the past decades.

Although there is a tremendous increase in the PNMS research, assessment and evaluation of the construct suffer from serious methodological errors. This is due to the absence of a multidimensional scale with good psychometric properties to assess the construct comprehensively.[1],[7] One of the major reasons for this could be attributed to poor conceptualization of the construct, and this often leads to inconsistent outcome in some studies.

Earlier studies had employed different approaches to assess PNMS, but much of this attention had given to stress, that is general or nonspecific to pregnancy.[8] During pregnancy, women are exposed to a wide variety of stressors ranging from pregnancy-specific issues such as: significant physical symptoms, changes in appearance, changes in interpersonal relationships, pain and fear of labor and delivery, parenting concerns, health of the fetus, and fear of medical complications[7],[9] to more generic daily hassles.[10]

Although pregnancy-specific stress tends to co-occur with general or nonspecific stress, some studies suggest a distinction between these two.[11] Since pregnancy-related stress is a more powerful predictor of birth outcomes, general stress measures are inefficient to assess this unique experience during pregnancy.[12]

Another major issue in PNMS research is the lack of a multidimensional approach in the assessment and evaluation of the construct. Previous studies focused on, listing down some specific stressors or stressful events rather than considering how these events were perceived by pregnant women. Studies indicate that a multidimensional approach to PNMS, conceptualizing stress as a combination of stressors, appraisal of stressful events and stress responses offers more consistent and compelling evidence for the adverse birth outcome.[13]

An efficient screening of PNMS is warranted largely due to the fact that the measures currently available are too general to assess pregnancy specific concerns or too specific to the extent that it covers only a few domains of prenatal stress[1] such as high-risk pregnancy,[14] worries about labor, and delivery[15] or stress specific to cultural contexts.[16]

Having a comprehensive scale, which adopts a multidimensional approach, will facilitate proper assessment and evaluation of the construct more efficiently. This will help to provide timely intervention to the vulnerable and thereby prevent a large number of adverse birth outcomes as well as postnatal depression among women. This also saves researchers and practitioners from the concerns of administering a battery of tests to assess the construct comprehensively, which is often impractical and time-consuming in a health care setting.

Reviews by Ross and McLean shows the prevalence of PNMS at 0.6%–7.7% and generalized anxiety disorder during the perinatal period as 8.5%.[17] This is the same as, or higher than anxiety among the general population.[17] Although there is an increasing recognition about prevalence and adverse impacts of stress and depression during the prenatal period, the gap still remains unaddressed toward a scale that captures the experience of pregnant women comprehensively, which is equally condemned by researchers and practitioners.[18]

Hence, the present study focuses on developing a comprehensive scale which is capable of assessing both general as well as pregnancy-specific stress by adopting a multidimensional approach to the construct, PNMS.

 Materials and Method

Phase 1: Development of the scale

Various dimensions of PNMS among pregnant women were considered to develop the initial pool of items. Forty items were developed under major dimensions identified after an exploratory study. These include fetal health and well-being, loss of fetus, general fear of childbirth, fear of labor pain and concerns related to future baby care and parenting concerns, the gender of the baby, financial concerns, care and attention of the family, and intimate partner relations.[19]

While developing the initial pool of items, the scope of the scale was set to wider context covering pregnant women belonging to different parity and trimester. To reduce threats to the validity of individual responses due to random or inattentive response, first-person reference were interspersed in almost all the items (e.g., “I am concerned….” or “I often feel…”) by asking the participants to rate their experience in a four-point scale ranging from 0 to 3. Hence rather than listing down the stressors, the items were worded efficiently to capture how they perceive these events and their unique experiences. Both positively and negatively worded items were included in the scale.

These 40 items were subjected to content validity assessment by 23 subject matter experts (SME) including gynecologists, nurses, and psychologists. Content validity ratio (CVR) and scale content validity index (S-CVI) (by following an averaging approach) were considered in the study. To avoid the element of chance, CVR of each of these items were compared with the critical value, CVRcritical which is calculated by considering the number of items and SMEs (this is 0.391 for the present scale).[20] Nine items with CVR less than critical value were discarded. S-CVI after removing nine items is 0.85. The remaining 31 items were finally considered for pilot testing. The resultant scale uses a 4-point Likert scale for response ranging from 0 to 3 based on the subject's experiences in the last few weeks. A response of 0 denotes “not at all” and 3 denote “very much so” [Appendix 1].[INLINE:1]

Phase 2: Pilot testing and field-testing of the scale


The study was conducted from November 2015 to October 2016 in two major private hospitals in Delhi: St. Stephens and Tirath Ram Shah. Pregnant women in their first trimester to last trimester, both primigravidae and multigravidae who are in the age group of 20–35, came for their monthly prenatal check-up either in the general or in private outpatient department were considered. A sample of 356 pregnant women (including pilot and main study) were involved. Women who were diagnosed with serious mental illness were excluded from the study.

Participation was solely based on informed consent. It was also ensured that all participants have basic understanding in the English language since all three questionnaires used in the study were administered in English. The demographic details of the participants are given in [Table 1].{Table 1}


Pregnant women who met the above criteria were approached by the researcher and were briefed about the purpose of the study. Those who gave their consent to be a part of the study were given the newly developed scale along with perceived stress scale-10 (PSS) item version and the World Health Organization (WHO) (five) well-being index (1998 version). The study was approved by the Internal Ethics Committees of the respective hospitals.

The scale was pilot tested on a sample of N = 48, internal consistency of the scale was measured using Cronbach's alpha. Since there was no ambiguity reported for any of the items, the final scale having 31 items were field tested without further modifications. The scores in the Likert scale were found to be normally distributed.


After validity assessment by SMEs, perceived PNMS scale (PPNMSS) was retained with 31 items, relevant to intimate partner relation, perceived social support, financial concerns, concerns about baby, pregnancy-specific concerns both physical and emotional, fear of labor and delivery and concerns due to poor planning and preparedness for pregnancy.

Results of the pilot test are are M = 26, SD = 10.5 for 48 pregnant women. Internal consistency using Cronbach's alpha is 0.80. The overall response rate for each item is >95%.

Results of the field test for N = 356 pregnant women are M = 29.59, SD = 11.94, and range is 3–67. Items were screened for item total correlation. Items 3, 25, and 27 with total item correlation, r < 0.2 were removed. Mean and SD of the remaining 28 item scale, are 27.36 and 10.46, respectively (N = 356). No items have multicollinearity or inter-item correlation coefficient >0.9. Reliability of 28 item PPNMSS was assessed using Cronbach's alpha (α = 0.83). No further items were removed since all items were found to improve the reliability of the scale.

To uncover the underlying factor structure of the PPNMSS, exploratory factor analysis (EFA) was conducted. Data were screened prior to the analysis. The initial dataset had 356 pregnant women. A pairwise removal of cases with missing values was performed to ensure, only valid cases were considered for analysis. Principal axis factoring with varimax rotation (orthogonal) using Kaiser normalization was conducted to explore the factor structure of the scale.

Kaiser-Meyer-Olkin (KMO) Test of sampling adequacy was performed to determine the suitability of the data for factor analysis. Bartlett test results were found statistically significant, this suggests the structure of the scale is suitable for factor analysis (KMO = 0.75, Bartlett test result; df = 378, p = 0.001).

EFA extracted eight factors having Eigenvalue >1. A review of the scree plot for conceptual interpretability of the factors was considered while determining the number of factors to be retained in the final scale [Figure 1]. Out of eight factors explored in the factor analysis, three factors with <3 items were removed. One more factor was removed further, considering the item retention criteria (items loaded strongly [i.e., ≥0.50] but not too strongly (≥0.90), to avoid redundant items which may create within-factor correlation measurement error) [Table 2]. The final scale was retained with 15 items under four factors.{Figure 1}{Table 2}

Convergent validity of the new measure was assessed by correlating the scores on 15 item PPNMS scale with PSS-10.[21] The results indicates a positive correlation significant at p < 0.05 (r = 0.84, N = 356, p = 0.01).

Divergent validity of the scale was assessed by correlating the scores on PPNMSS with the WHO (five) well-being index (1998 version). Pearson correlation coefficient shows a strong negative correlation significant at p < 0.05 level (r = −0.81, N = 356, p = 0.01).

Internal consistency of each of these factors was assessed separately using Cronbach's alpha. The first factor, perceived social support and preparedness having items: 11, 23, 12, and 24 has a Cronbach's alpha 0.77 and all the items contribute to improving the internal consistency reliability of the factorial composition.

The second factor, pregnancy-specific concerns: including physical and emotional concerns during pregnancy, having items 18, 2, 1, 10, and 14 have a Cronbach's alpha 0.74. Cronbach's alpha of the third factor, intimate partner support, and perceived stress, having items 19, 21, and 31 is 0.76, and finally, the fourth factor, financial concerns consisting of items 4, 16, and 9 have Cronbach's alpha 0.69 and all the items contributes to improve internal consistency of the factor structure of the scale.

In the paired sample t-test, these four factors had shown a significant relation with the total scale score; indicating each of these factors is a major constituent of the construct PNMS. Mean and range of the final 15-item PPNMS scale and the four factors are given in [Table 3].{Table 3}

A comparison was made between women belonging to different parity and employment status (housewives and employed women) on the PPNMS scale and on four factors. Only 46% of working women have a score >2 on financial concerns (N = 356, M = 2.44 and range is 0–9), whereas 70% of house wives have scores >2 on the same. This suggests that non working women have higher financial concerns as compared to working pregnant women.


Importantly, all the four factors explored in the initial EFA are conceptually clear. The first factor, F1 consists of items related to perceived social support and preparedness for pregnancy, while the second factor, F2 consists of items related to physical and emotional concerns during pregnancy, the third factor, F3 consists of items related to intimate partner relation and the fourth factor, F4 consists of financial concerns and concerns about future baby care.

Though the scale has a positive correlation with PSS-10, correlation is not strong with all the individual dimensions of PNMSS. This clearly states a general stress scale is not as efficient as a comprehensive multidimensional scale to assess PNMS.

The negative correlation of the scale with the WHO well-being index denotes, women who were prenatally stressed are at a higher risk of having compromised health and well-being which is a potential risk among pregnant women.[22]

A strong loading of items related to preparedness and adaptability to pregnancy along with perceived social support is in consistent with previous studies which indicate: Social support prepares women to adapt to new roles,[23],[24] this helps her to be more responsive to the baby thereby strengthens the mother-child bonding.

Studies also suggest that lack of social support may lead to depression among women[25] and may negatively affect the health of the baby. Hence, mental health of pregnant women is strongly influenced by her perceived social support, and it prepares her to accept the challenges of being pregnant and to adapt to new roles without much internal conflicts.

A strong loading of items related to physical and emotional concerns during pregnancy as a distinct factor, factor 2 suggests that pregnancy-specific concerns are distinct from other general concerns.[16]

Items loaded on the third factor includes, items related to women's satisfaction in their marital life and care and attention of their intimate partner. Those items related to general satisfaction and well being in life was also loaded on this factor, indicating marital satisfaction is an important component that determines well-being of married women and this is in consistent with previous studies which identified a greater well-being among women who reported higher satisfaction in their marital life.[26] A higher score in this dimension indicates lower well-being and less satisfaction in intimate partner relations.

A strong loading of items related to financial concerns as a distinct factor, factor four, is in consistent with previous studies[26],[27] which identified financial concerns as one of the major components of PNMS among women belongs to lower economic status. Item related to concerns about future baby care was also strongly loaded on this factor, which may indicate, those who have higher financial concerns may experience more concerns about future baby care, or one of the major reasons for concerns about future baby care is poor financial conditions, which highlight the need for family planning.

On various demographic factors, results are in conformity with earlier studies which associate a significant level of maternal anxiety among primigravidae as compared to multigravidae.[28] However, there is no significant difference between the scores of primigravidae and multigravidae on any specific factor.

Interestingly, no significant difference is found on PNMS among working and nonworking pregnant women on the entire scale as well as on any of its four factors. However, there is a notable difference in the scores on financial concerns among working women and housewives, since working women are financially independent and this gives them a sense of confidence to raise their family. Further investigation is required to explore the relation between economic status and well-being of pregnant women, and such studies should be followed by adequate interventions.


In summary, the factor structure of PPNMSS came out to be a four-factor model having 15 items and was found to be a comprehensive scale to assess PNMS among pregnant women belonging to different parity, trimester, and diverse socioeconomic background.

The 15 items of PPNMSS belongs to four factors such as Perceived social support, pregnancy-specific concerns (both physiological and emotional), intimate partner relations and financial concerns. A positive pregnancy experience is associated with higher perceived social support and intimate partner relations, better physical and emotional adjustments to pregnancy, and lower financial concerns and concerns about future baby care. A strong negative correlation with the WHO-5 well-being index shows that the scale is efficient in assessing the construct comprehensively.

Being a comprehensive scale with the multidimensional approach and diagnosable reliability, health care professionals could rely on the scores of the new measure for assessment and early detection of stress among pregnant women. This facilitates timely intervention to save the mother and the child from the potential risks of PNMS.

Since stress, depression, and anxiety are higher among pregnant women, PPNMSS comes handy to both researchers and practitioners, as a reliable measure to improve the mental health and well-being of pregnant women and the study also enrich the existing knowledge about PNMS among various healthcare professionals.


The authors would like to acknowledge the cooperation and support provided by the staffs of Tirath Ram Shah and St. Stephen's hospital and all the participants in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Alderdice F, Lynn F, Lobel M. A review and psychometric evaluation of pregnancy-specific stress measures. J Psychosom Obstet Gynaecol 2012;33:62-77.
2Dole N, Savitz DA, Hertz-Picciotto I, Siega-Riz AM, McMahon MJ, Buekens P, et al. Maternal stress and preterm birth. Am J Epidemiol 2003;157:14-24.
3O'Donnell KJ, Bugge Jensen A, Freeman L, Khalife N, O'Connor TG, Glover V. Maternal prenatal anxiety and downregulation of placental 11β-HSD2. Psychoneuroendocrinology 2012;37:818-26.
4Lobel M, Hamilton JG, Cannella DL. Psychosocial perspectives on pregnancy: Prenatal maternal stress and coping. Soc Pers Psychol Compass 2008;2:1600-23.
5Saunders TA, Lobel M, Veloso C, Meyer BA. Prenatal maternal stress is associated with delivery analgesia and unplanned cesareans. J Psychosom Obstet Gynaecol 2006;27:141-6.
6Talge NM, Neal C, Glover V, Early Stress, Translational Research and Prevention Science Network: Fetal and Neonatal Experience on Child and Adolescent Mental Health. Antenatal maternal stress and long-term effects on child neurodevelopment: How and why? J Child Psychol Psychiatry 2007;48:245-61.
7Bayrampour H, Ali E, McNeil DA, Benzies K, MacQueen G, Tough S. Pregnancy-related anxiety: A concept analysis. Int J Nurs Stud 2016;55:115-30.
8Lobel 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.
9Kornelsen J, Stoll K, Grzybowski S. Development and psychometric testing of the rural pregnancy experience scale (RPES). J Nurs Meas 2011;19:115-28.
10Woods SM, Melville JL, Guo Y, Fan MY, Gavin A. Psychosocial stress during pregnancy. Am J Obstet Gynecol 2010;202:61.e1-7.
11Meades R, Ayers S. Anxiety measures validated in perinatal populations: A systematic review. J Affect Disord 2011;133:1-5.
12Dunkel Schetter C. Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues. Annu Rev Psychol 2011;62:531-58.
13Lobel M, Dunkel-Schetter C, Scrimshaw SC. Prenatal maternal stress and prematurity: A prospective study of socioeconomically disadvantaged women. Health Psychol 1992;11:32-40.
14Goulet C, Polomeno V, Harel F. Canadian cross-cultural comparison of the high risk pregnancy stress scale. Stress Med 1996;12:145-54.
15Redshaw M, Martin C, Rowe R, Hockley C. The oxford worries about labour scale: Women's experience and measurement characteristics of a measure of maternal concern about labour and birth. Psychol Health Med 2009;14:354-66.
16Kazi A, Fatmi Z, Hatcher J, Niaz U, Aziz A. Development of a stress scale for pregnant women in the South Asian context: The A-Z stress scale. East Mediterr Health J 2009;15:353-61.
17Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: A systematic review. J Clin Psychiatry 2006;67:1285-98.
18Chandra PS, Ranjan S. Psychosomatic obstetrics and gynecology – A neglected field? Curr Opin Psychiatry 2007;20:168-73.
19Gangadhran S, Jena SP. A comprehensive understanding of prenatal maternal stress. Indian J Psychol Sci 2018;9:86-7.
20Wilson FR, Pan W, Schumsky DA. Recalculation of the critical values for Lawshe's content validity ratio. Meas Eval Couns Dev 2012;45:197-210.
21Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
22Mortazavi F, Chaman R, Mousavi SA, Khosravi A, Ajami ME. Maternal psychological state during the transition to motherhood: A longitudinal study. Asia Pac Psychiatry 2013;5:E49-57.
23Brockington IF, Macdonald E, Wainscott G. Anxiety, obsessions and morbid preoccupations in pregnancy and the puerperium. Arch Womens Ment Health 2006;9:253-63.
24Mwape L, McGuinness TM, Dixey R, Johnson SE. Socio-cultural factors surrounding mental distress during the perinatal period in Zambia: A qualitative investigation. Int J Ment Health Syst 2012;6:12.
25Hung CH. The hung postpartum stress scale. J Nurs Scholarsh 2007;39:71-4.
26Sawyer A, Ayers S, Smith H, Sidibeh L, Nyan O, Dale J. Women's experiences of pregnancy, childbirth, and the postnatal period in the Gambia: A qualitative study. Br J Health Psychol 2011;16:528-41.
27Ohman SG, Grunewald C, Waldenström U. Women's worries during pregnancy: Testing the Cambridge worry scale on 200 Swedish women. Scand J Caring Sci 2003;17:148-52.
28Cheung W, Ip WY, Chan D. Maternal anxiety and feelings of control during labour: A study of Chinese first-time pregnant women. Midwifery 2007;23:123-30.