Psychosocial Correlates of Psychological Distress among First Time Pregnant Mothers

Objective: The study investigated the relation of marital relationship and social support with psychological distress in first time pregnant women. Study Design: Correlational design. Setting and Duration: The study was carried out in Lahore, Pakistan, over a period of six months. Subjects and Methods: The sample of the present study includes 100 pregnant first time mothers. Sample of pregnant females was collected from the maternity ward of different hospital located in Lahore. Pregnant females included in sample were falling with the age range of 20-35 years, the minimum duration of their marriage was at least 2 years and minimum qualification was intermediate. Those women were selected who had no history of psychological problem and had never been on any kind of psychiatric/ psychological treatment (psychotropic medication /psychotherapy). The participants completed the Demographic Information sheet, Depression Anxiety and Stress Scale, Relationship assessment Scale and Social Provision Scale. Responses were scored according to the producer given in the manuals. Results: Mean ± SD of age was 26.21 ± 2.8 years. Significant (p<.05) relationship was found between marital relationship and psychological distress among first time mothers whereas social support was also significant predictor of psychological distress among first time mothers. Conclusion: It is to be concluded that quality of marital relationship and social support affects on psychological distress of first time pregnant women.


INTRODUCTION
A woman undergoes various changes during pregnancy.During the time of pregnancy significant changes accrued in every woman's physical and mental health.Many women face depression, dissatisfied marital relationship and isolation during this time period.Pregnancy is the short interval in married woman's life but it influences profoundly on every aspect of their life.In the current study we therefore investigate to what extent the marital relationship and social support affects psychological distress of pregnant women.
Obstetric technologies are going to advance now; professionals are more concerned about fetal wellbeing.They perceived that a healthy pregnant woman is the healthy pathway for the unborn child so they became more focused on the needs of fetus at the expense of mother.It is observed that health care providers and researchers as well are more concerned about what type of quality services provided to the mother and child.Counseling on preconception is an advance and excellent opportunity to provide primary care regarding pregnancy with a keen focus on prevention [1].
*Address correspondence to this author at the University of Central Punjab, Lahore, Pakistan; Tel: 03002661136; E-mail: uroojsadiq_icp@yahoo.com Women with first time early pregnancy take this event as life opening in terms of both life sustaining and suffering [2], including depression, anxiety and stress which may cause developmental and emotional problems in children e.g.ADHD, conduct disorder and impaired cognitive development [3].Among many correlates of psychological distress during pregnancy current study focuses on marital relationship and social support.Marital relationship described as satisfaction in relationship with the spouse, expectation met in the relationship, affection towards the partner, desirability to sustain the relationship, and conflict in the relationship" are the baseline factors of marital relationship [4].
A study was conducted on 51 pregnant women by revealing that during pregnancy if the relationship is satisfactory then it can guards against risk factors including somatic disease, emotional difficulties, and work stress.Similarly, if the women experienced dissatisfied relationship then it can become the largest cause of maternal emotional distress [5].Women who perceived strong support from their partners had lower chances to develop emotional distress [6].
Although, support from partner do play a vital role in developing psychological vulnerability in first time mothers however, many times support from spouse is not enough and women also needs support from her family and friends during this phase of vulnerability.Social support is an interpersonal exchange in which one person gives help to another [7].
A recent study documented that those expectant mothers who have benefited with positive social and emotional support from their partners, family and even social networks during pregnancy are less likely to develop peripartum complications.For instance those pregnant women who receive lack of social support during their pregnancy are at high risk of developing psychological problems such as distress, anxiety disorders, inferiority complex and depression [8].Positive social support reduces the risk of depressive symptoms during maternal antenatal days which lead positive health and pregnancy outcomes [9].
Many other evidences targeting the reduction of anxiety, depression and stress in expectant mothers should be a cost-efficient method to improve problems such as low birth weight, prematurity and particularly neurodevelopment problems.These programs might include policies regarding maternal employment and parental leave, but should not equally direct the activities and actions of all pregnant women because stress is a subjective experience that is not rigidly dictated by environmental events.All new intervention programs should be evaluated as to child outcome.

METHOD Participants
The sample of the present study includes 100 first time pregnant woman.

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Duration of marriage minimum of 2 years.
• Educational level was from Intermediate and above.

Exclusion Criteria
• Known cases of mood/anxiety and other psychiatric illness.
• Second or third time pregnant women

Demographic Information Sheet
The demographic information sheet was used to pick the participants that best fit the purpose of the research.This demographic sheet, designed by the supervisor and researcher was used to determine various demographic variables such as age, gender, occupation, duration of marriage, gender expectation, duration of pregnancy, education, family systems etc.

Depression Anxiety and Stress Scale (Lovibond, &Lovibond, 1995) [10]
The DASS 21 consisted on 21 item self-report questionnaire which used to measure the levels of some symptoms common to Stress, Depression and Anxiety.Dependent variable of the current was Psychological Distress which include all above elements, Depression, Anxiety and Stress so DASS 21 was the most appropriate scale to measure psychological distress.It is the shorter form of version DASS which has 42 items.The scoring procedure includes levels of severity i.e. mild, moderate and severe.The score fall within these levels will show the intensity of Stress, Depression and Anxiety.Cronbach's alphas were .90 for Depression, .83 for Anxiety, .86 for Stress.Cronbach alpha of DASS 21 also computed in the current study was .87.

Relationship Assessment Scale (Hendrick, 1988) [11]
Different instruments developed previously which used to measure satisfaction in relationship but most of them are time consuming.The relationship assessment scale is the brief scale which measure relationship satisfaction.This scale consists of seven items each rated on five-point likert scale.The relationship assessment scale is appropriate for any individuals who experience an intimate relationship, such as married couples, and engaged couples.The shortness of the scale boosts its efficacy in clinical settings and for online administration.Research has shown this scale can also be used to measures other factors like love, sexual attitudes, commitment, and investment in a relationship (Hendrick, 1988).The test-retest reliability of RAS was .85).The Cronbach Alpha was computed in the current study was .94.

Social Provision Scale (Cutrona & Russel, 1987) [12]
The Social Provisions Scale consists of 24 items and its ratings were made on a 4-point Likert-type scale ranging from strongly disagree to strongly agree.This is most dependable and suitable measure developed to evaluate the perceived social support.This scale measures the six provisions of social relationships including, guidance, reliable alliance, reassurance of worth, attachment, social integration, and opportunity for nurturance and a high score indicates a greater degree of perceived support.The report of test-retest reliability coefficient ranging from .37 to .66.

Data Collection
The study was conducted after the formal approval Graduate Research Committee (GRC), University of Central Punjab, Lahore.Maternity ward of different hospitals located in Lahore city was approached to collect data of pregnant women.Permission from the respective authorities of hospital was taken for data collection.Consent was taken from participants who were taking part in the research and each one of them was assured of privacy and confidentiality of their information and identity.In addition to this, the participants were informed about their participation in the research as purely voluntary, and the freedom to withdraw from participating in the research if they feel like.They were also be notified that the information obtained from them will be used purely for academic purposes, thus willing consent will be taken.

Data Analysis
Data was analyzed with SPSS version 21.Descriptive statistics of frequencies, percentages and means were calculated for the demographic variables of age, gender and family structure, duration and type of marriage, birth order, education and occupation.Linear Regression analysis was done to analyze predictive relationship of marital relationship and social support affect the psychological distress among first time pregnant women.

RESULTS
Table 1 shows descriptive statistics, mean and standard deviation of age.Table 2 describes the descriptive statistics, mean and standard deviation of sub-scales of Depression, Anxiety and Stress Scale.The findings of linear regression presented in Tables 3,  4, 5 and 6.
Table 1 show that the mean age of the sample is 26.21 years.

Quality of Marital Relationship Predicts Psychological Distress among First Time Pregnant Women
The variables of marital relationship and psychological distress were included in a linear regression analysis to evaluate the contribution of quality of marital relationship in the prediction of psychological distress among first time pregnant women.

Social Support Predicts Psychological Distress among First Time Pregnant Women
The variables of social support and psychological distress were included in a linear regression analysis to evaluate the contribution of social support in the prediction of psychological distress among first time pregnant women.

DISCUSSION
According to this result quality of marital relationship and social support during pregnancy has negative impact on pregnant women.If quality of marital  During pregnancy especially if it happens first time after marriage, women want more support from their partner as well as from their family or friends.Hence the role of family is also significant for pregnant women during antenatal days.
If we look onto those factors which can influence the results of the study with respect to demographics are family structure, duration of pregnancy, husband's working hours and monthly family income.If family structure is nuclear then it can be stressful for the pregnant women who experience it first time.When husband go to his work then women would feel lonely and there is no one with whom she can talk or share her feelings.Consequently she may experience distress.
A recent study reported about 20 percent of expectant mothers experience emotional confusion and relationship issues during pregnancy.If couples have the better understanding of problems which can influence the quality of marital relationship during pregnancy in advance, they can easily solve majority of the problems during this phase.If couples learn to tackle their problems effectively it means they can enjoy the phase of pregnancy to its fullest [13].
Pregnancy is a significant event which affects a female as well as a male.Expectant fathers also suffer from this changing phase.Their concerns, stressors are different but they also have been through distress during this phase.Expectant fathers reported high prevalence of psychological distress during their wives pregnancy [14].However, pregnant women many times are only focused on their needs while ignoring the first time expectant fathers' stressors.When males find themselves alone in handling their stressors of being a parent, their quality of providing support to their wives consequently gets effected which may increase distress in pregnant women.It can be assumed that supportive relationships with husband have a positive effect on mental health of pregnant women during pregnancy and it further bring forth the feelings of happiness and makes pregnancy related changes less stressful for the expectant mother.
During first time pregnancy only partner's support is not enough.Social support which includes family, friends are also important for the pregnant women.When a pregnant women talks to other females who have already experienced this phase it proves to be beneficial for her as she shares her feelings with them and make them understand her state.When the significant others are not there for her, it can contribute towards higher levels of psychological distress during pregnancy.Another recent study stated that family and social support is strongly associated with outcomes of pregnancy as well as its side effects [15].It is also evident in the physiological field that during a stressful event social support had a suppressing effect on the level of cortisol and anxiety scores of participants, [16].This buffering effect has also found in pregnant women.
From the study it can be concluded that the quality of marital relationship and social support plays a vital role in developing psychological distress in pregnant women.The role played by the spouse and family contributes in mental health of pregnant women.However, pregnancy can also be a powerful stressor.Presence of stress during pregnancy may lead to different perinatal difficulties that may have long-term consequences on the newborn.
The findings of the study can be implicated in many areas to bring betterment in pregnancy outcomes.The findings can assist in advance obstetric technologies.Obstetric providers can make policies about giving essential information to the women who experience pregnancy first time.Many private maternity clinics in western countries have developed certain special policies related to provide information about maternal health and they also offer child birth classes.In our society these findings can help the private hospitals or maternity clinics to develop separate departments to provide information.The information must include knowledge about pregnancy, emotional health of pregnant women during pregnancy, importance of spousal support and its effects on women's mental health during pregnancy and this information will not only for the female but also for that male who is going to be a father.When pregnant women visit to the doctor, psychotherapeutic treatment should also be done by psychologist along with gynecologist.With the current findings obstetric providers should engage psychologists with them to provide couple therapy and family therapy and it should be scheduled on any visit of the pregnant women.