1. Introduction
As the modern medical model develops, psychological health has been increasingly given more attention. Previous researches have shown a high prevalence of psychiatric illness in pregnant women [
1,
2], not only in the developed countries, but also in developing countries such as Turkey [
3]. Furthermore, a large body of research exists on the adverse outcomes of maternal psychological ill health [
4,
5], most notably depression and anxiety during pregnancy. For example, psychiatric illness during pregnancy is considered to contribute to prematurity, low birth weight and obstetric complications [
6,
7].
Antenatal anxiety, as a common form of psychiatric illness, is a reflection of stress response [
8], which occurs when personal well-being is threatened during pregnancy. Antenatal anxiety has been thought to be related to attention-deficit/hyperactivity disorder in children born to women who experience such antenatal anxiety [
9,
10,
11,
12]. It is believed that change in maternal hypothalamic–pituitary–adrenal (HPA) axis activity and fetal over exposure to glucocorticoids are potential pathogenetic factors in these adverse outcomes [
13,
14]. Findings from some studies indicated that anxiety is more common during pregnancy than depression and often co-morbid with depression, even related to the occurrence of postnatal depression across many countries [
7,
15,
16]. Studies have examined the prevalence and its associated factors of postnatal depression [
17], whereas only a few studies have explored the prevalence of anxiety in pregnancy.
Antenatal anxiety is believed to be a psycho-biological process, which means that it is also influenced by complex biological systems, particularly the endocrine system. The fluctuation of estrogen and progesterone may also induce anxiety among pregnant women [
18]. Regarding the fact that endocrine system change largely, it is possible that antenatal anxiety rise as birth approaches [
19].
In Chinese culture, there exists a widespread gender preference for male progeny. For a long time, this preference led to a high number of sex-selected abortions of female fetuses, contributing to an unequal male-to-female ratio. Today, fetal sex determination is forbidden, which may increase the level of anxiety in pregnant women who have a preference for a male child, because of the uncertainty of the fetal sex. A study in Bangladesh reported a 29% high prevalence of antenatal anxiety regarding the gender sensitivities in their country [
20]. Similarly, there may be a potentially high prevalence of anxiety among Chinese women. While there are studies on postpartum depression and gender preference [
21], little research is available on either the prevalence or factors associated with antenatal anxiety in China. A study in Hong Kong showed a negative relationship between feelings of control during labour and maternal anxiety. However, given the economic and cultural differences between Hong Kong and mainland China, it is difficult to extrapolate the findings of the study to our region of China [
22]. Furthermore, the prevalence of antenatal anxiety varies widely from 9.1% to 59.5% assessed by different scales [
19,
23,
24,
25], scarce work has been done to examine the prevalence in China.
Thus, given the potential high prevalence and its possible adverse effects of antenatal anxiety [
26], the authors wanted to determine the prevalence of prenatal anxiety in Changchun, Jilin Province, Northeast China, and to understand the associated risk factors during antepartum hospitalization. We hope that by raising the awareness of maternal prenatal anxiety among health care professionals and caregivers, mothers will be screened early in their pregnancy and offered personalized services for their psychological health in order to reduce, distress and improve pregnancy outcomes [
27].
4. Discussion
Although obstetric intervention for physical care of pregnant women has improved dramatically in China over the past several decades, little attention has been paid to emotional care. This study is performed to assess the incidence of antenatal anxiety during pregnancy as well as associated risk factors in the Chinese population in mainland China.
This study finds that antenatal anxiety is prevalent in approximately one-fifth of the pregnant women in this study (20.6%), which is consistent with a Brazilian study that found a high prevalence of antenatal anxiety [
38]. In contrast, studies from developed Asian countries have reported a lower prevalence of such anxieties. For instance, a study on a sample of Singaporean women who were hospitalized during pregnancy shows that 12.5% of those women suffered from anxiety disorders [
39]. Although socio-economic factors can cause anxiety, pregnancy could be an important alternative explanation. Most of the participants surveyed in our study were at least 38 weeks into their pregnancy, which is a point when they could deliver at any time. Therefore, it is likely that most of these women, who were in their third trimester, were experiencing a marked amount of physical discomfort, which could lead to anxiety [
40]. Although the prevalence of estimated antenatal anxiety may vary significantly across different studies due to different sampling methodologies and measurement errors [
41,
42], these studies agree that anxiety is a common and significant problem during pregnancy and that antenatal anxiety has become an important public health issue, particularly in developing countries.
Moreover, our study shows that pregnancy-induced hypertension syndrome and anemia during pregnancy are the major risk factors of antenatal anxiety among pregnant women. However, to our knowledge, the literature on antenatal anxiety with pregnancy complication is limited. A previous research had shown that pregnant women in hospitals tended to become more anxious and vulnerable when they were in poor health [
23], which is consistent with our study. Also, in another study, pregnant women with preeclampsia reported complete shock and tended to suffer from high anxiety due to fear of babies’ prematurity, loss and guilt [
43]. Therefore, pregnant women with complications should be given more psychological care from caregivers and their families, which could diminish the occurrence and development of antenatal anxiety.
Besides, this study has revealed that anxiety during pregnancy is associated with natural delivery method. To our surprise, our study found that planned cesarean deliveries, including those requested by the mother without medical reasons, were more common than planned natural deliveries (283
vs. 184). The fear of giving birth and experiencing a natural delivery is a real challenge for women, and this fear is strongly linked to the request for a cesarean section. Pang
et al. found that women voluntarily elected cesarean sections after having their first child, even when they had attempted to give birth naturally in the past [
37]. There are many unknown factors during pregnancy that cannot be controlled and that sometimes result in emergency cesarean deliveries, including situations involving intrauterine growth restriction, which eventually threatens the mother’s or the baby’s life. In addition, pregnant women are conscious during natural childbirth, are without the use of analgesics or anesthetics, and experience labor pain for at least a few hours. We suggest that these worries and fears contribute to the escalating prevalence of antenatal anxiety. According to Maier, for pregnant women, a planned cesarean section is a well-tolerated procedure, psychologically, when compared to natural childbirth [
44]. Thus, as psychophysical care is an integral part of childbirth, professionals and caregivers need to pay close attention to women’s psychological status in the management of pregnancy and labor pain.
Our study finds a statistically significant relation between disharmony in family relationship and anxiety, whereas, conjugal relationship is believed to be important for mental health disorders. However, the exact mechanism by which disharmony in family relationship affects anxiety remains unclear. We infer that a lack of social support is a possible factor that eventually influences help-seeking behaviors [
45]. Some studies have found that people in lack of social support tend to suffer from mental illnesses than those with adequate social support. Pregnant women in absence of social support are apt to be pessimistic and suffer from low self-esteem or self-worth [
46]. Interestingly, this is consistent with studies on paternal anxiety during pregnancy, which is due to low self-esteem and poor social support [
47]. In particular, individuals in these surroundings of disharmony are less likely to seek useful support or help, suggesting the importance of social support during pregnancy, especially family care.
In our study, we also found that pregnant women with lower levels of education were at a higher risk for developing anxiety during pregnancy. Some other studies have also found this association between poor education and mental health [
48]. A lower level of education is correlated with a lower socioeconomic status, and individuals with these qualities lack adequate resources and information to improve their situation during pregnancy. A job-education mismatch is believed to influence mental health [
49]. In our study, although there was not a significant relationship between the participants’ type of job and their anxiety level, we think education may have a stronger contribution to antenatal anxiety. Further, the results of our study indicate a significant association between life satisfaction and antenatal anxiety. In this respect, our findings highlight the importance of screening pregnant women dissatisfied with their lives so that the professional caregivers can provide more psychological care to the most vulnerable ones. In this way, we can recognize and decrease the incidence and the harmful consequences of antenatal anxiety effectively.
5. Limitations
Our study has the following limitations: First, because of limited resources and time constraints, we conducted the study in only one regional hospital in Changchun where the available sample group was small; thus, the results are not representative all of pregnant women in China. Secondly, gender preference, an important factor in the psychological health of pregnant Chinese women, and its influence on antenatal anxiety, could not be assessed in our study. Third, as a cross-sectional design study, we could not identify the change of anxiety throughout pregnancy, and finally, this study was not designed to study the relationship between anxiety and depression during pregnancy, nor its impact on psychological health in postpartum period.