Objectives: Stress and anxiety during pregnancy period might have a negative impact on mother-baby attachment. In this study, it was aimed to evaluate the effect of increased stress on prenatal attachment in high-risk pregnancies.

Material and methods: 195 pregnancies with high-risk pregnancy and 87 pregnancies without any risk factors were included in the study. The Perceived Stress Scale and Prenatal Attachment Inventory were applied to all patients in this study and the findings of healthy pregnant women were compared with women with high-risk pregnancy.

Results: Age (25,55±4,40 vs 28,99±5,65, p<0,001), gravida (2,02±1,18 vs 3,01±1,84, p<0,001), parity and number of living children of the high-risk pregnancy group were higher. Although the perceived stress level in high-risk pregnancy group was higher than the control group (17.37±5.98 vs 13,95±5.36, p<0.001), the prenatal attachment was similar in both groups. (p>0.005). When the factors affecting prenatal attachment in pregnancy were examined prenatal attachment was found to be lower in women older than 35 years (52,92±9,65 vs 57,75±9,56 p:0,005), who have  a higher number of pregnancies (r: -0,311, p<;0,001), a lower socio-economic level (49,89±11,02 vs 58,14±9,06 p<0,001), a lower level of education (r:0,139, p:0,020), who smoke (53,47±9,22 vs 58,04±9,61 p:0,001), and when the current pregnancy is unplanned (52,35±9,21 vs 58,57±9,39, p<0,001).

Conclusion: As a result, although the perceived stress increases in high-risk pregnancy it does not have a negative impact on the prenatal attachment.


Although pregnancy is a natural phenomenon, it leads to neuroendocrine, hormonal, and psychosocial changes that makes this period of women’s life quite different from other periods of her life [ 1 ]. In addition to the biological and physiological changes in pregnancy, various conflicting thoughts, hope and expectations emerge depending on the emotional, vital and social status of the women. For this reason, there is an escalated

risk of encountering many factors that might cause anxiety and stress during pregnancy.  In high-risk pregnancies, worries about the health status of the mother and the offspring and the outcome of the pregnancy augments the stress and the anxiety [ 2 ].

High-risk pregnancy is defined as a condition that affects the physiological and psychosocial health of the mother and the baby, increasing the risk of mortality and morbidity. The increased stress experienced in high-risk pregnancies might affect the establishment of a strong bond between the mother and the baby in the prenatal period [ 2 ].

The bond between parents and unborn children is known as prenatal attachment. The mental health of the woman in the prenatal period is strongly related to the health of the baby [ 3 , 4 , 5 ]. Attachment starts when a woman responds positively to pregnancy. It is known that the relationship between neonate and mother in the postpartum period is strongly related to the prenatal attachment. Before delivery, women are reported to have four specific tasks: seeking a safe transition period for both the baby and herself, ensuring that the baby is specifically accepted by other individuals, attachment to the baby and devotion to the baby [ 4 , 6 ].

Perceived stress in high-risk pregnancies is expected to increase and affect prenatal attachment negatively in this process [ 2 ]. This study aims to investigate the effect of perceived stress on prenatal attachment in women with high-risk and normal pregnancies.


This study was carried out between April 01, 2016 and July 31, 2016 in Adiyaman University Faculty of Medicine, Training and Research Hospital, Department of Obstetrics and Gynecology (Adiyaman University Faculty of Medicine Ethics Committee Decision Number: 2016/3-8).

In this descriptive study, the sample size; the 5% error level was calculated to be 282 with 0.89 representing power in the 95% confidence interval. Sample selection was performed using simple random sampling method. Among pregnant women admitted to our clinic between the given dates 282 pregnant women who were literate, psychologically healthy, did not have any communication difficulty and mental impairment, and accepted to participate in the study by giving a signed informed consent and had a viable singleton pregnancy with a gestational age > 20 week were included to the study. Following inclusion criteria out of 282 who were eligible, 87 women were taken as normal pregnancy group and 195 were included in the high- risk pregnancy group.

Inclusion Criteria for high risk pregnancy group was as follows; presence of at least one of the following conditions was considered as having a high-risk pregnancy: maternal age greater than 35, having a pre-pregnancy body mass index (BMI) <19 or> 30, presence of maternal systemic illness (hypertension, heart disease, asthma, epilepsy, diabetes mellitus, kidney disease, autoimmune diseases (eg systemic lupus erythematosus), thyroid diseases, sexually transmitted diseases), smoking, alcohol or substance dependency, and having a bad obstetric history; (history of preterm birth, stillbirth narrative or having a baby with congenital anomaly -especially with congenital heart disease and genetic problems-

Women who did not want to participate, who are illiterate or had communication difficulty, mental retardation, psychiatric disease or multiple pregnancy were not included in the study.

Collection of data: The data was obtained by a single investigator through face-to-face interviews with eligible pregnant women who agreed to participate in the study. The interviews were conducted in a quiet room other than the examination room and were not scheduled at the day of the antenatal examination or medical treatment.

Demographic, obstetric characteristics and the mode and delivery of the pregnant women were recorded. The women were asked whether the pregnancy was planned. Smoking, alcohol or other addictions of the women during gestational period and presence of a health problem in the antenatal period was questioned. Perceived Stress Scale (PSS) and Prenatal Attachment Inventory (PAI) tests were applied to all of the patients in both groups.

Perceived Stress Scale (PSS) was developed by Cohen et al. in 1983 [ 6 ], and the Cronbach Alpha value was 0.8 6 in the reliability study. In this study, the scale adapted to Turkish and validated by Eskin et al. [ 7 ] was used and the Cronbach Alpha value was 0.75 in the reliability study. The three items of the scale prepared in the likert type of 5 (0 no, 4 too often) are inverted (4th, 5th, 6th items) and the five items are the plain ones (1st, 2nd, 3rd, 7th, 8th items). The scale is scored between 0-32 in total. There are two subscales, perceived stress (1st, 2nd, 3rd, 7th, 8th items) and perceived coping (4th, 5th, 6th items). The scale is evaluated on both the total score and the subscale scores. The higher the total score, the higher the level of perceived stress. The high scores on the subscales are also negative.

Prenatal Attachment Inventory (PAI) was developed by Mary Muller in 1 9 9 3 [ 8 ]. Yilmaz and Beji adapted to Turkish and validated in 200 9 [ 9 ]. The scale developed to analyze the thoughts, feelings and situations that women experience during pregnancy and determine the attachment levels in the prenatal period to babies is composed of 21 items. The scale is scored between 21 and 8 4. Each item can be scored 1 to 4 in the Likert type (1: Never, 2: Sometimes, 3: Frequently, 4: Always). The increased score indicates increased level of attachment [ 8 ]. Turkish validity and reliability of the scale were reported by Yilmaz and Beji and the internal consistency factor was reported as 0.84 [ 9 , 10 ].

Statistical Analysis: SPSS for Windows (Statistical Package for Social Science for Windows, Version 15.0) package program was used to analyze the data. Descriptive tests were used for statistical analysis; for parametric data independent sample t test and for nonparametric data Mann Whitney U test was used. Correlation tests were performed with Pearson for parametric data and Spearman Correlation test for nonparametric data. Categorical data were compared with the Chi-square test. Statistical significance was accepted as p <0.05.


The socio-demographic characteristics of the groups are given in Table 1 . According to this, in the high-risk pregnancy group, the average age, gravida, parity, abortion and number of living children were higher than the control group ( 25,55±4,40 vs 28,99±5,65, p <0,001 , 2,02±1,18 vs 3,01 ± 1,84, p <0,001 , 0,69 ± 0,96 vs 1,43 ± 1,55, p <0,001, 0,34 ± 0,69 vs 0,58 ± 0,96 , p: 0.36; 0.69 + 0.98 vs 1.29 + 1.47, p: 0.001). However, no statistically significant difference was found between the two groups in terms of educational status of the women and their spouses, working rates of the pregnant women, monthly income perception levels, planned pregnancy rates, average gestational weeks at the time of evaluation, gender of the infants and number of ante-natal visits (p> 0,05).

The average age of marriage is significantly higher in the high-risk pregnancy group. (3,91±3,81 vs 6,32±4,96, p<0,001). Also, while 57 (%29.2) patients smoke in the high-risk pregnancy group, there were no patients using alcohol. There were 24 (12.3%) patients with preterm delivery history.

PSS, the perceived stress sub-dimension, perceived coping sub-dimension averages and total score were significantly higher in the high-risk pregnancy group than in the normal pregnancy group ( Table 2 ) (11.07±4.53 vs 8.41±4.26, p <0.001; 6.30±2.62, vs 5.54+1.96, p: 0.016; 17.37±5.98 vs 13,95±5.36, p <0.001 respectively). There was no difference between the two groups in terms of the total mean score of the prenatal attachment inventory ( Table 2 ) (58,71±9,51 vs 56,40±9,72, p: 0,064) in comparison with the high detection of perceived stress in high-risk pregnancies.

When perceived stress and prenatal attachment were assessed according to subgroups: Perceived stress was similar in women aged ≤ 35 and women > 35 (p> 0.05), but prenatal attachment was significantly lower in women > 35 (52,92±9,65 vs 57,75±9,56, p: 0,005). Infant’s gender had no effect on perceived stress and prenatal attachment (p> 0.05). Perceived stress was statistically significantly higher and prenatal attachment statistically significantly lower in in women with unplanned pregnancies (17,67±5,32 vs 15,90±6,15 p: 0,036 and 52,35±9,21 vs 58,57±9,39 p<0,001). While PSS score was statistically significantly lower in working women (14,36±6,09 vs 16,76±5,91 p: 0,011), PAI score was similar (57,94±9,31 vs 56,94±9,79 p: 0,507). There was no significant difference in PSS and PAI of women who had a history of still birth when compared with women who did not have (p>0,05). Although PSS was similar in smokers (16,84±6,13 vs 16,18±5,98 p: 0,459), PAI is statistically significantly lower (53,47±9,22 vs 58,04±9,61 p: 0,001). PSS was higher and PAI was lower in women from low income families when compared to the middle and high-income families (19,97±4,54 vs 15,80±6,01 p<0,001 and 49,89±11,02 vs 58,14±9,06 p<0,001).

When the relationship between ASS and PAI and other parameters was examined, there was no significant relationship between perceived stress and prenatal attachment (p> 0,05). While there was a positive relationship between duration of marriage and PSS (r: 0.166, p: 0,005), there was a negative correlation between the duration of the husband’s education and PSS (r: -0.127, p: 0.033). While there was a negative correlation between prenatal attachment and age of marriage (r: -0,193, p: 0,001) and duration of marriage (r: -0,271 p <0,001); women’s (r: 0,139, p: 0,020) and spouse's education (r: 0,162, p: 0,006) and prenatal attachment were found to be positively correlated. When the relationship between the number of pregnancies and perceived stress was examined, a positive correlation was found (r: 0,184, p: 0,002). Conversely, there was a negative correlation between the number of pregnancies and prenatal bonding (r: -0.311, p <0.001) ( Table 3 ).


There are a number of factors that affect perceived stress and prenatal attachment in pregnancy. The age of the women, obstetric history, socioeconomic status and other environmental factors are well-known contributors to perceived stress. The average age, duration of marriage and number of pregnancies in our study were significantly higher in the high-risk pregnancy group compared to the control group. This finding may be related to the one of the inclusion criteria for high-risk pregnancy group; being older than 35 years. No statistically significant difference was found between the two groups in terms of educational status of the women and their spouses, working status of the women, perceived monthly income, percentage of unplanned pregnancy, average gestational weeks at the time of the interview, number of antenatal visits and gender of the infants.

It is known that the perceived stress will increase in the presence of a maternal and/or fetal problem. This is thought to affect prenatal bonding in high-risk pregnancies [ 2 ]. Similarly, our study also found that perceived stress was significantly higher in the high-risk pregnancy group than that of the control group (17.37 ± 5.98 vs. 13,95 ± 5.36, p <0.001), but no difference was found between the two groups (58,71 ± 9,51 vs. 56,40 ± 9,7 2 , p: 0,064) in terms of mean prenatal attachment inventory scores (although slightly lower in the high-risk pregnancy group). The mean PAI scores were consistent with the literature in both groups. Although some studies have shown that the psychological state of pregnancy affects prenatal attachment [ 11 ], no relationship was found between PSS scores and PAI scores in pregnant women in our study.

Some studies have shown that parity and maternal age has an impact on prenatal attachment [ 11 , 12 , 13 ]. Our study also showed that the increased number of pregnancies increased perceived stress and reduced prenatal attachment. Compared with women ≤ 35 years old prenatal attachment was found to be lower in women > 35 years old while the perceived stress level was similar in both age groups.

Unplanned pregnancy is shown to effect bonding in published studies [ 14 , 15 ]. In the presented study, the perceived stress was lower and prenatal attachment was higher in planned pregnancies. As shown in other studies, the monthly income, level of education is shown to be factors affecting perceived stress and prenatal bonding in the presented study [ 16 , 17 , 18 ].

Lindgren found that there is a strong prenatal attachment in pregnancy, showing positive health behaviors during pregnancy, avoidance of tobacco, alcohol and illegal drugs, and receiving antenatal care [ 19 ]. In our study, smokers who smoked during pregnancy were found to have lower prenatal bonding scores, presumably reflecting their negative health behavior that did not alter during pregnancy.


In our study groups, the perceived stress was found to be increased in high-risk pregnancies, while having a high-risk pregnancy did not affect prenatal bonding. In our study, it was shown that the factors that increase perceived stress in pregnancy are low educational or economic status, unemployment of the women, having an unplanned pregnancy and increased number of pregnancies. Factors that affect the prenatal bonding negatively are; advanced maternal age, unplanned pregnancy, and low socioeconomic level, increased number of pregnancies, low educational status and smoking during pregnancy. The limitation of this study is the limited number of women recruited. In order to generalize the findings of this study multicentric studies with higher numbers of women are required.

Control Group N:87 High-Risk Pregnancy Group N: 195 p
Age (years) (mean±SD) 25,55±4,40 28,99±5,65 <0,001*
Gravidy (Median (Min-Max)) 2,02±1,18 3,01±1,84 <0,001*
Parity (Median (Min-Max)) 0,69±0,96 1,43±1,55 <0,001*
Abortion (Median (Min-Max)) 0,34±0,69 0,58±0,96 0,036
Number of living children (Median (Min-Max)) 0,69±0,98 1,29±1,47 0,001
Duration of education(years) (mean±SD) 10,33±3,37 9,50±3,60 0,069
Working rate (n, %) 16 (18,4) 34 (17,4) 0,846
Spouse’s duration of education years) (mean±SD) 11,16±3,38 10,42±3,77 0,114
Duration of marriage (years) (mean±SD) 3,91±3,81 6,32±4,96 <0,001*
Perceived Monthly Income (n, %) Good 24(27,6) 51(26,2) 0,331
Middle 56(64,4) 116(59,5)
Bad 7(8,0) 28(14,4)
Number of women who have a planned pregnancy (n, %) 68(78,2) 148(75,9) 0,678
Number of antenatal follow-up during this pregnancy (mean±SD) 8,56±3,77 8,38±4,22 0,728
Gestational age mean±SD) 34,98±3,15 34,02±4,03 0,051
Gender of the baby (n, %) Girl 39(44,8) 104(53,3) 0,187
Male 48(55,2) 91(46,7)
* P< 0.05 statistically significant

Demographic properties of group

Control Group N:87 High-Risk Pregnancy Group N: 195 p
PSS 13,95±5,36 17,37±5,98 <0,001
PSS 1 8,41±4,26 11,07±4,53 <0,001
PSS 2 5,54±1,96 6,30±2,62 0,016
PAI 58,71±9,51 56,40±9,72 0,064
By age groups 18-34 age N:245 ≥35 age N:37 p
PSS 16,33±5,88 16,19±6,84 0,891
PAI 57,75±9,56 52,92±9,65 0,005
Baby’s Gender Girl N:143 Male N:139 P
PSS 15,58±5,95 17,07±5,98 0,037
PAI 57,57±9,43 56,65±9,97 0,427
Status of the pregnancy Planned N:216 Unplanned 66 P
PSS 15,90±6,15 17,67±5,32 0,036
PAI 58,57±9,39 52,35±9,21 <0,001
Working status Working N:50 Housewife N:232
PSS 14,36±6,09 16,76±5,91 0,011
PAI 57,94±9,31 56,94±9,79 0,507
History of stillbirth delivery Previous Stillbirth Delivery (+) N: 19 No Stillbirth N: 263 P
PSS 15,95±6,37 16,34±5,99 0782
PAI 55,37±10,81 57,24±9,62 0,418
Smoking Smoking N:57 Non-smoker N: 225 P
PSS 16,84±6,13 16,18±5,98 0,459
PAI 53,47±9,22 58,04±9,61 0,001
Perceived Monthly Income Low N:35 Middle and Upper n: 247 P
PSS 19,97±4,54 15,80±6,01 <0,001
PAI 49,89±11,02 58,14±9,06 <0,001
PSS: Total score from the perceived stress scale test, PSS 1: Perceived stress subscale average, PSS 2: Perceived coping sub-dimension averages and PAI: Prenatal attachment inventory score.

Perceived stress and prenatal binding in two patient groups

Perceived Stress Prenatal Attachment
Age R: 0,035 P: 0,558 R: -0,193 P: 0,001
Gravidy R: 0,184 P: 0,002 R: -0,311 P<0,001
Duration of education ( School years ) R: -0,050 P: 0,405 R: 0,139 P: 0,020
Spouse’s Educational Status R: -0,127 P: 0,033 R: 0,162 P: 0,006
Duration of marriage R: 0,166 P: 0,005 R: -0,271 P<0,001
Prenatal Attachment R: -0,010 P: 0,867

Relation of perceived stress and prenatal attachment to demographic data