Anxiety symptoms during pregnancy and risk of adverse birth outcomes in Gondar Town Ethiopia  – Nature.com 06:10 

Scientific Reports volume 15, Article number: 35475 (2025) Cite this article

Abstract

Anxiety is the most common complication of pregnancy and childbirth and is reported to have a plethora of adverse maternal, birth, and childhood outcomes. There is a lack of studies that looked at the association between pregnancy-related anxiety and the risk of adverse birth outcomes in Ethiopia. We conducted a community-based prospective cohort study in Gondar Town to explore the link between anxiety symptoms during pregnancy and the risk of adverse birth outcomes (low birth weight (LBW), preterm, and stillbirth). We used the three questions listed in the Edinburgh Postnatal Depression Scale (EPDS-3 A) to assess the presence of anxiety symptoms during pregnancy. We explored both association and causal effects using modified Poisson regression and the Targeted Maximum Likelihood Estimation (TMLE), respectively. We also calculated the population impacts of risk factors significantly associated with adverse birth outcomes. Of 916 mothers who made up a cohort, 895 completed follow-ups and were included in the final analysis. No evidence of an association was found between anxiety symptoms during pregnancy and: LBW (Adjusted incidence rate ratio (aIRR) = 1.20; 95%CI: 0.49, 2.94), preterm birth (aIRR = 0.77; 95%CI: 0.36, 1.64), and stillbirth (aIRR = 3.29; 95%CI: 0.96, 11.29, p = 0.058). However, other psychosocial factors such as maternal fearful thoughts about delivery and poor stress-coping ability contributed to 34.9% (95% CI: 10.3, 52.7) and 38.3% (95% CI: 12.6, 56.5) of preterm births, respectively. Supportive husbands, on the other hand, averted about 14.7% (95% CI: 5.1, 27.1) of premature births. About 90.0% (95%CI: 82.2, 94.4) and 54.1% (95%CI: 15.0, 75.2) of the risk of LBW was attributed to preterm birth and smoking in pregnancy. There was no evidence of an association between anxiety symptoms during pregnancy and adverse birth outcomes. Other psychosocial factors contributed to or averted adverse birth outcomes. Early screening followed by providing proven psychological interventions is key for reducing individual and population-level impacts of psychosocial risk factors associated with adverse birth outcomes.

Introduction

Perinatal mental disorders that mainly encompass anxiety and depression are the most common complications of pregnancy and childbirth1. Anxiety symptoms generally manifest as feelings of tension, worried thoughts, increased heart rate, rapid breathing, and sweating2. Pregnancy-related anxiety is a specific and distinct multidimensional form of anxiety that occurs during pregnancy, mainly manifested as pregnancy-specific fears and worries about the well-being of the fetus, own health, childbirth, and change in physical body image related to the pregnancy3. Recent studies in Ethiopia reported a prevalence of anxiety in pregnancy ranging between 4.7 and 43.7%4,5, which potentially varies with gestational age and ways of measurement. There are a plethora of pregnancy-related anxiety measurement tools, but there is a lack of common consensus tools developed to measure anxiety symptoms specific to pregnancy6.

Perinatal common mental disorders are associated with a high level of cortisol hormone production, which significantly affects fetal growth leading to adverse birth outcomes mainly preterm, Low Birth Weight (LBW), and fetal death7. Preterm (birth before 37 weeks of gestation) and LBW (birth weight less than 2500gm) are leading causes of child mortality and morbidity, and lifelong disability8 and are also reported to be associated with later incidences of chronic non-communicable disease (diabetes mellitus, cardiovascular disease)9. Pregnancy-related anxiety can indirectly increase the risk of adverse birth outcomes by increasing the risk of pregnancy complications from infection, malnutrition, and changing maternal healthy pregnancy behavior10,11. Children born to women with common pregnancy-related mental disorders are also at an increased risk of being stunted and underweight, failing to thrive, and early cessation of breastfeeding12,13,14,15,16.

Previous systematic reviews have reported a significant link between common pregnancy-related mental disorders (mostly depression and stress) and adverse pregnancy, birth, and child developmental outcomes8,17,18,19,20,21 with inconsistent findings reported in Ethiopian studies22,23,24,25,26. A plethora of studies have investigated the link between antenatal depression and adverse pregnancy outcomes but there are lack of studies that specifically looked at the effect of anxiety symptoms during pregnancy in Ethiopia. Though there are overlaps of symptoms and similarities of mechanisms causing adverse pregnancy outcomes between antenatal depression and anxiety symptoms during pregnancy, evidence peculiar to pregnancy-related anxiety might be important to guide some specific interventions. We conducted this study to investigate the link between anxiety symptoms during pregnancy and adverse birth outcomes using both association and causal models. We also conducted further analysis to determine the population attributable fractions (PAF) and population preventive fractions (PPF) for risk factors associated with unfavorable birth outcomes.

Methods

Study design and population

We conducted a community-based cohort study that followed pregnant women from any time during the second trimester until birth in Gondar Town from June 1, 2018, to March 20, 2019. Gondar Town is in the Northern part of the Amhara region at 747 km away from Addis Ababa. This study was a part of a big project designed to explore the extent of perinatal mental disorders and their risk of adverse birth and infant health outcomes27,28,29. We determined the sample size for the whole project using a double population proportion formula in Epi Info version 730 with the following assumptions: a 95% confidence level, a 90% power, exposed to the non-exposed ratio of 1:2, a prevalence of low birth weight (LBW) among those free from common mental disorder of 25%, and to detect a relative risk (RR) difference of 1.5. We calculated a sample size of 809 and added a further 20% to account for expected losses to follow-up, after which the final sample size for the cohort reached 970 women. However, because of the nature of cluster sampling, we got 942 mothers.

Data collection

We conducted a face-to-face interview with mothers in their homes to assess the required exposure variable (anxiety symptoms during pregnancy), confounders, and covariates of adverse birth outcomes. We used the three questions listed in the Edinburgh Postnatal Depression Scale (EPDS-3 A) as stated in the revised and validated version of EPDS in the Ethiopian context31 to assess the presence of anxiety symptoms during pregnancy—the main exposure of interest. A cut-off point of 6 or more32,33 was used to declare the presence of anxiety symptoms during pregnancy. The main outcome variables included: preterm birth—birth occurring before 37 completed weeks of gestation34, low birth weight—birth weight below 2500 g34, and stillbirth—the death of the fetus after 20 completed weeks of gestation or intrauterine death of a fetus before the onset of labor, or intrauterine death of the fetus during labor and delivery35. The gestational age of the mothers was calculated based on the last normal menstrual period (LNMP) obtained from the mothers during the ANC visit and was triangulated with ultrasonography information. Health extension workers—who are trained nurses—are recruited from their specific destricts as data collectors and assigned to specific households and asked to follow mothers from pregnancy through delivery. Health extension workers then accompanied mothers to the health facility on the day of delivery and recorded the birth outcomes directly. We used the Oslo Social Support Scale (OSSS-3)36 to measure mothers’ support during pregnancy and categorized as poor if a total score was less than nine and moderate to strong support if a score was 9–14. We assessed maternal stress coping levels by four customized internally consistent coping subscales called Perinatal Coping Inventory (PCI-4)37.

Data analysis

We downloaded data from the Google Cloud Platform and imported it to the Stata 14 for further analysis. We used the Modified Poisson regression model to estimate the association between anxiety symptoms during pregnancy and adverse birth outcomes38. The Modified Poisson regression made a precise estimation of relative risk that is nearly similar to Mantel-Haenszel, very robust to omitted covariates39,40, and efficient for clustered data41. Covariates with a p-value < 0.2 in the bi-variable analysis and those found repeatedly significant in previous studies were adjusted in the multi-variable model. Seaparately, we emulated a target trial to estimate the causal effect of anxiety symptoms during pregnancy on adverse birth outcomes. Using TMLE, we adjusted for measured confounders and derived the ATE under standard causal assumptions. We fit a separate causal model using the Targeted Maximum Likelihood Estimation (TMLE). The TMLE is a doubly robust approach that combines outcome estimation, exposure estimation using Inverse Probability Weighting (IPW), and a targeting step to optimize the parameter of interest concerning bias/ variance42,43. We estimated the Average Exposure Effect (AEE) of anxiety symptoms during pregnancy44,45—the AEE estimates the average difference in the outcome between the exposed participants had they been exposed, and the same exposed participants had they been unexposed adjusting for potential confounders46. We checked multicollinearity using the correlation coefficient and Variance Inflation Factor (VIF) with a cut-off value of ≥ 80% and ≥ 10, respectively47. We calculated adjusted Population Attributable Fraction (PAF)48 for risk factors associated with adverse birth outcomes and Prevented Fraction for the Population (PFP) for protective risk factors of adverse birth outcomes49. We also estimated the area under the receiver operating characteristics curve (ROC)50.

Results

About 916 pregnant women were screened for anxiety symptoms during pregnancy and were included in the follow-up. During the follow-up, we interviewed 895 (97.7%) women to assess their birth outcomes, while seven refused to participate and 14 lost to follow-up, most of whom moved their residence. There was no difference between women who were screened and women who were interviewed in terms of the exposure, outcome, and other covariates. The socio-demographic characteristics of the study participants are described in Table 1 supplementary information. The obstetric and psychosocial characteristics of the study participants are presented in Table 2 supplementary information. LBW was more common among women with unplanned pregnancies (9, 6.8%), previous adverse birth outcomes (4, 8.9%), had exposure to tobacco (38, 9.4%), good social support (42, 5.9%), low husband support (14, 8.5%), and underweight (9, 7.0%).

Anxiety symptoms during pregnancy are not associated with low birth weight (Adjusted incidence rate ratio (aIRR) = 1.20; 95%CI: 0.49, 2.94), preterm birth (aIRR = 0.77; 95%CI: 0.36, 1.64), and still birth (aIRR = 3.29; 95%CI: 0.96, 11.29, p = 0.058). Our causal model also confirmed that anxiety symptoms in pregnancy are not a sufficient cause for low birth weight (Average exposure effect (AEE)= -1.0; 95%CI: -5.6, 3.7), preterm birth (AEE = 2.6; 95%CI: -5.8, 10.9), and stillbirth (AEE=-3.0; 95%CI: -7.4, 1.30). (Table 1)Table 1 Association and causal estimation between anxiety symptoms during pregnancy and adverse birth outcomes in a mother-child cohort in Gondar town, Ethiopia, 2018–2019.

Full size table

In the adjusted association model, preterm birth (aIRR = 10.04; 95%CI: 5.62, 17.94) and mothers’ exposure to cigarette smoking (aIRR = 2.18; 95%CI: 1.18, 4.04) were significantly associated with risk of LBW. The estimated Population Attributable Fraction (PAF) of LBW was 90.0% (95%CI: 82.2, 94.4) for preterm birth and 54.1% (95%CI: 15.0, 75.2) for cigarette smoking and could have been averted if the mothers were protected from preterm birth and cigarette smoking during pregnancy. The risk of preterm birth was 54% (95%CI: 1.11, 2.12) higher in mothers who had fearful thoughts about delivery and 62% (95%CI: 1.14, 2.30) higher in mothers who had poor stress-coping ability during pregnancy. The associated PAF for preterm birth was 34.9% (95%CI: 10.3, 52.7) for mothers with fearful thoughts about delivery and 38.3% (95%CI: 12.6, 56.5) for mothers with poor stress coping ability that could have been averted had the mothers were early screened and consulted about their fearful thoughts and encouraged to develop their stress coping ability. Conversely, mothers who reported having supportive husbands during pregnancy had a 0.54 (95%CI: 0.35, 0.79) times lower risk of having a preterm birth. The population prevented fraction of preterm birth due to husband support was 14.7% (95%CI: 5.1,27.1), conversely equating to 22.0 (95%CI: 7, 40) premature births averted. (Table 1) A PAF of stillbirth reaching 69.6% (95%CI: -0.4, 91.1) and 62.0% (95%CI: -16.8, 87.6) was estimated for anxiety symptoms during pregnancy and maternal low nutrition status, respectively that could have been averted by illuminating these risks. (Table 2).Table 2 Population-attributable fraction (PAF) of risk factors associated with adverse birth outcomes in Gondar town, Ethiopia, 2018–2019.

Full size table

Discussion

In this study, anxiety symptoms during pregnancy did not appear to be a risk factor or a cause of LBW and preterm birth but were marginally associated with stillbirth. Various genetic and environmental factors including hormonal fluctuations, physical and emotional demands of pregnancy and lack of support and resilience to various stressors could predispose pregnant mothers to risk of common mental disorders including anxiety51,52. In our study husband support and stress coping ability tended to reduce the risk of preterm birth potentially playing a buffering role or improving the resilience of the mother toward the onset and severity of anxiety. The long- and short-term complications of adverse birth outcomes could lead to perinatal death, newborn morbidity, poor childhood developmental outcomes, and risk of chronic complications at a later age12,53,54. Epidemiological studies have reported a significant statistical association between restricted fetal growth and adverse birth outcomes55,56,57. There are also suggested potential biological mechanisms that explain the link between restricted fetal growth and maternal anxiety during pregnancy, which could be prevented by protecting pregnant mothers from developing anxiety symptoms. Stress and anxiety symptoms during pregnancy enhance maternal hypothalamus–pituitary–adrenal (HPA) system activity and in turn, increased cortisol hormone secretion leads to restricted fetal growth58,59,60,61 and premature labor62. The other potential explanation of the link between maternal mental health during pregnancy and adverse birth outcomes is through environmental predisposition. Mothers with common mental disorders including anxiety are more likely to have inflammation or infection of reproductive organs, low health service uptake, and poor health behaviour, which all these factors appeared to be associated with adverse birth outcomes in this study63,64,65,66,67. Anxiety symptoms during pregnancy can also be indirectly linked to adverse birth outcomes by increasing the risk of complications during pregnancy68,69.

In this study, maternal anxiety symptoms during pregnancy are not associated with the risk of all birth outcomes. There are inconsistencies in study findings from developed countries related to the link between generalized anxiety disorders and the risk of adverse fetal and birth outcomes70,71. Maternal fear of giving birth is a main symptom of pregnancy-related anxiety that is most of the time associated with adverse birth outcomes rather than maternal generalized anxiety disorders3,72. Our result also supports this observation, as we found that pregnant women who experienced fearful thoughts about delivery were 54% more likely to have preterm births. Stress-coping ability and having good social support during pregnancy are important buffers of stressors that help to lower emotional disorders helping perinatal women to have better personal and newborn health and child outcomes73,74. Consistently our study also indicated that pregnant mothers with good husband support and stress-coping ability had a reduced risk of preterm birth. Our finding is also supported by a review of randomized controlled studies that reported offering support for pregnant women to slightly reduce the number of preterm babies75. Similar cohort studies also found a positive effect of behavioural therapy during pregnancy on good birth outcomes and a buffering effect of maternal perceived support from a husband76,77. The bio-psychological model is an emerging concept that shifts our traditional view of health and disease from completely medical or biological towards psychological and social, in which recent studies around perinatal health also emphasised this concept and strongly highlighted the importance of perinatal mental health in the reduction of maternal and child mortality78,79,80. Our findings show the importance of maternal mental health in birth outcomes and one way to intervene to improve birth outcomes could be to integrate maternal mental health services into perinatal healthcare.

Limitation

We measured anxiety symptoms using a tool that has not been validated in the study area and might lead to potential exposure misclassification. There are potential unmeasured confounders such as violence and maternal-specific complications during pregnancy and might mask the true link between anxiety symptoms during pregnancy and adverse birth outcomes.

Conclusion

Psychosocial risk factors have appeared to importantly explain a path that leads to adverse birth outcomes. Though anxiety symptoms during pregnancy was not associated with the risk of LBW, preterm birth, and stillbirth. Furthermore, maternal fearful thoughts about a delivery, stress coping ability, and lack of husband support during pregnancy are associated with an increased risk of preterm birth. The population-attributable and preventive fractions of these psychosocial risk factors were also high indicating their public health importance in averting the risk of adverse birth outcomes in a population. Further studies might be needed in the area with an improved method of anxiety assessment during pregnancy to establish vivid evidence for policy input.

Data availability

Data included in article/supp. material/referenced in the article.

Abbreviations

aIRR:

Adjusted incidence rate ratioAEE:

Average exposure effectEPDS-3A:

Edinburgh postnatal depression scale anxiety scales

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Authors and Affiliations

  1. Menzies School of Health Research, Charles Darwin University, Darwin, AustraliaAbel F. Dadi
  2. Addis Continental Institute of Public Health, Addis Ababa, EthiopiaAbel F. Dadi
  3. Center for Women’s Health Research, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, AustraliaTahir A. Hassen
  4. The George Institute for Global Health, University of New South Wales (UNSW), Sydney, AustraliaDaniel B. Ketema
  5. School of Public Health, Medicine College of Health Science, Debre Markos University, Debre Markos, EthiopiaDaniel B. Ketema & Addisu A. Alemu
  6. Rural Health Research Institute, Charles Sturt University, Orange, NSW, 2800, AustraliaKedir Y. Ahmed, Zemenu Yohannes Kassa & Meless G. Bore
  7. College of Medicine and Health Sciences, Hawassa University, Hawassa, EthiopiaZemenu Yohannes Kassa
  8. Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, AustraliaErkihun Amsalu
  9. St. Paul Hospital Millennium Medical College, Addis Ababa, EthiopiaErkihun Amsalu
  10. Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2109, AustraliaGetiye Dejenu Kibret
  11. School of Women’s and Children’s Health, University of New South Wales Sydney, Kensington, AustraliaAddisu A. Alemu
  12. School of Nursing and Midwifery, University of Technology Sydney, Sydney, AustraliaJemal E. Shifa
  13. Palliative Care Outcomes Collaboration, Australasian Health Outcomes Consortium, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, AustraliaAnimut Alebel Ayalew
  14. Psychiatry Department Shashemene, Madda Walabu University, Robe, EthiopiaJemal E. Shifa
  15. First Nations Cancer and Wellbeing (FNCW) Research Program, School of Public Health, The University of Queensland, Brisbane, AustraliaHabtamu M. Bizuayehu

Contributions

Conceptualisation: AFD. Formal analysis: AFD. Investigation: all. Methodology: all. Validation: all. Writing original draft: AFD. Writing review & editing: all. All author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Abel F. Dadi.

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The authors declare no competing interests.

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This study was reviewed and approved by the Institutional Review Board of the University of Gondar with approval number O/V/P/RCS/05/1601, 2018. All participants/patients (or their proxies/legal guardians) provided informed consent to participate in the study. All participants/patients (or their proxies/legal guardians) provided informed consent for the publication of their anonymised case details and images. All methods were performed in accordance with the relevant guidelines and regulations.

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Dadi, A.F., Hassen, T.A., Ketema, D.B. et al. Anxiety symptoms during pregnancy and risk of adverse birth outcomes in Gondar Town Ethiopia. Sci Rep 15, 35475 (2025). https://doi.org/10.1038/s41598-025-19379-8

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