Women & Health

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Coping strategies during pregnancy and their

relationship with anxiety and depression

Isabel Artieta-Pinedo, Carmen Paz-Pascual, Maite Espinosa, Arturo García-

Alvarez, the ema-Q Group & Paola Bully

To cite this article: Isabel Artieta-Pinedo, Carmen Paz-Pascual, Maite Espinosa, Arturo
García-Alvarez, the ema-Q Group & Paola Bully (2023): Coping strategies during
pregnancy and their relationship with anxiety and depression, Women & Health, DOI:
10.1080/03630242.2023.2188097

To link to this article: https://doi.org/10.1080/03630242.2023.2188097

Published online: 20 Mar 2023.

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WOMEN & HEALTH
https://doi.org/10.1080/03630242.2023.2188097

Coping strategies during pregnancy and their relationship with

anxiety and depression
Isabel Artieta-Pinedo RN, CNM, PhD a,b,c, Carmen Paz-Pascual RN, CNM a,b,d
,
Maite Espinosa MD b,e, Arturo García-Alvarez MD b,e, the ema-Q Group f
,
and Paola Bully MD g
a
Primary Care Midwife OSI Barakaldo-Sestao Osakidetza Basque Health Service, Bizkaia, Spain; bBiocruces-Bizkaia
Health Research Institute, Bizkaia, Spain; cSchool of Nursing, University of the Basque Country, Bizkaia, Spain;
d
Midwifery Training Unit of Basque Country, Bilbao, Spain; eOsakidetza Basque Health Service-OSI General
Management, Bizkaia, Spain; fThe ema-Q Group: Multidisciplinary Group of Midwives, Medical Professionals,
Psychologists and Researchers of Osakidetza Basque Health Service and University of Basque Country, Bizkaia, Spain;
g
Methodological and Statistical Consulting, Bizkaia, Spain

ABSTRACT ARTICLE HISTORY

How individuals perceive and cope with stressful situations may determine Received 11 August 2022
their level of anxiety or depression. The identification of coping strategies (CS) Revised 15 February 2023
in pregnancy could help prevent depression and anxiety (D&A), and their Accepted 1 March 2023
consequent effects on the health of the mother and the baby. A cross-sectional KEYWORDS
descriptive correlational study was conducted to identify the CS most com­ Anxiety; coping; coping
monly used by pregnant women in a Spanish population and to evaluate the strategies; depression;
association of these CS with D&A. A consecutive sample of 282 pregnant midwifery; pregnancy
women over 18 years of age were recruited when attended midwife consulta­
tions and through snowball sampling between December 2019 and
January 2021 in the Basque public health system. CS were measured using
the RevisedPrenatal Coping Inventory (NuPCI) questionnaire, assigning the
score to an avoidant, preparatory or spiritual scale. Cutoff points were estab­
lished to categorize anxiety and depressive symptomatology, using the STAI-S
and EPDS scales. Multivariate logistic regression models were constructed to
analyze the association between CS and D&A. The results show that the higher
the score on the avoidance subscale, the higher the likelihood of having an
anxiety disorder (OR: 8.88 (95 percent Confidence Interval [CI] 4.26–20.1), and
depressive symptoms (OR: 8.29 (95 percent CI 4.24–17.4). Multiparous women
are more likely to have anxiety (OR: 3.41 (95 percent CI 1.58–7.5) or depressive
symptomatology (OR: 4.1 (95 percent CI 2.04–8.53) during pregnancy. These
results highlight the need to consider the evaluation of CS used during
pregnancy to tailor the care provided, but further studies on the implementa­
tion and effectiveness of interventions are needed.

Introduction
Contrary to popular belief, pregnancy is not always a period of placid waiting. On the contrary, the
potentially uncomfortable physical changes, uncertainty during the process, fear of complications and
pain during childbirth, or insecurity about future motherhood can be associated with high, constant
stress for women, which can lead to anxiety disorders or depression (Guardino and Dunkel Schetter
2014; Ibrahim and Lobel 2020; Molgora, Fenaroli, and Saita 2020). High levels of anxiety or depression
during pregnancy can favor the adoption of unhealthy behaviors (Nicoloro-SantaBarbara et al. 2017),

CONTACT Maite Espinosa maite.espinosacifuentes@osakidetza.eus Osakidetza Basque Health Service-OSI General

Management, Biocruces-Bizkaia Health Research Institute, Ed. Biocruces 3- BIOCRUCES-BIZKAIA, C/Plaza De Cruces, Barakaldo
48903, Spain
© 2023 Taylor & Francis Group, LLC
2 I. ARTIETA-PINEDO ET AL.

and are frequently associated with poor obstetric outcomes, a higher rate of premature births and a low
birth weight newborn (Goletzke et al. 2017; Peñacoba Puente et al. 2021).
According to Lazarus and Folkman’s (1984) transactional theory of stress and coping, individuals
constantly evaluate stimuli in their environment. This appraisal process generates emotions, and
when stimuli are appraised as threatening, challenging, or harmful (i.e., stressors), coping strategies
are put in place to manage the emotions or attempt to directly address the stressor itself. The result
of the coping efforts, accompanied by new information from the environment, leads to a process of
cognitive reevaluation, initiating a new cycle always in the search for balance. In accordance to this
theory, coping strategies aim to directly manage the stressor (problem-focused coping, PFC) or to
regulate the emotions that arise as a consequence of the stressful encounter (emotion-focused coping,
EFC). Researchers may also distinguish between approach or engagement coping, referring to efforts
aimed at dealing with the stressor itself, either directly or indirectly, as compared to avoidance or
disengagement coping, which refers to efforts to escape from having to deal with the stressor
(Guardino and Dunkel Schetter 2014). Both strategies can be adaptive in the short term; however,
when exploring their influences in the long term, approach coping predicts improved psychological
health and well-being, whereas avoidance has been related to a decrease in the outcome (Peñacoba
Puente et al. 2021). Other authors (Hamilton and Lobel 2008; Penengo et al. 2020) classify
pregnancy-specific coping into three types: a) positive coping, which is based on preparation and
planning, and focuses on the problem to be solved, b) negative or avoidant coping, focusing on the
emotions felt, in which the person aims to escape from the distressing situation and c) “spiritual”
coping, in which the person faces up to the situation by relying on a higher power (Giurgescu et al.
2006; Guardino and Dunkel Schetter 2014).
Pregnancy, with uncertainty or fear of childbirth and parenting, can lead to stress which the
woman tries to escape from through behaviors such as self-isolation, overeating or lack of exercise,
which in turn are associated with problems of anxiety and even depression (Gourounti,
Anagnostopoulos, and Lykeridou 2013; Lau et al. 2016; Lau, Wang, and Kwong 2015). In contrast,
the adoption of planning-preparation coping strategies, based on the acquisition of knowledge,
preparation of the home, seeking social support or taking exercise, would improve the woman’s
sense of control and confidence. The ways of coping used by women could be related to the culture
of origin (González-Mesa et al. 2018; Lau et al. 2016; Yu et al. 2020), with personal characteristics
such as previous experiences and knowledge, age, parity (Goletzke et al. 2017), or may even vary in
the same person over time (Ockhuijsen et al. 2014). Most of the studies on coping and distress in
pregnancy have focused on women with high-risk pregnancies (Giurgescu et al. 2006; Ibrahim and
Lobel 2020). Because of their medical history, high-risk pregnant women use to be more problem-
focused coping strategies and have higher levels of psychological distress than did low-risk pregnant
women. In contrast, women with low-risk pregnancies may have less fear of childbirth (Christiaens,
van de Velde, and Bracke 2011) and could use other coping strategies, so their study is of interest.
For example, in Loren-Guerrero’s work and Penengo’s study, both focused on low-risk pregnant
women, the most commonly used coping strategy was Planning-Preparation, but in Hamilton &
Lobel’s study, with a sample of ethnically and socioeconomically diverse women of different medical
risk the predominant strategy was Spiritual coping. The latter study and Penengo’s study included
early, mid and late pregnancies, while the women in Guerrero’s study are assessed at the time of
discharge after childbirth.
Although there may be some stability in the way a person copes with stress (coping styles), coping
is a dynamic process that responds to the changing course of stressful conditions (Hamilton and
Lobel 2008; Lazarus and Folkman 1984). For this reason, when studying coping, it is important to
examine a situation over time and situation-specific demands (Hamilton and Lobel 2008). In 2018,
a cross-sectional study was performed to evaluate the psychometric properties of NuPCI adapted for
a Spanish population (Lorén-Guerrero, Gascón-Catalán, and Romero-Cardiel 2018). Participants
were 261 puerperium women completed the NuPCI at the time of discharge after childbirth. Women
were asked how often they used different types of coping to try to manage the stress and challenges
 WOMEN & HEALTH 3

of being pregnant during the last month, as posed in the NuPCI questionnaire. However, because
the coping strategies used by women may vary depending on the time of gestation, the Loren-
Guerrero results may not be extrapolable to the general population of pregnant women, at any given
week of gestation, due to their focus on the final stretch of pregnancy. The Pelengo study does
include women at any week of gestation in its sample, but it is a study conducted in a different
country, and as mentioned above, culture may be an influential variable. The objectives of the study
are, therefore, to identify the coping strategies most widely used by pregnant women – at any stage of
pregnancy – in the Spanish population, to evaluate their association with psychological well-being
(anxiety and depression) and to explore whether certain relevant sociodemographic variables in
pregnancy could be related to these coping strategies. Furthermore, as an intermediate step, the
metric properties of the Spanish version of the coping questionnaire will be analyzed to verify that its
characteristics are still adequate when including women at all stages of gestation.

Method
Design and selection of participants
The data is part of a broader investigation that analyses the perceptions and needs of women during
pregnancy, childbirth and postpartum, and the resources they have available to adapt to the new
situation. Clinical Research Ethics Committee of Euskadi (Spain) approved this study (Ref:N°
PI2019110). The study protocol has been published previously (Paz-Pascual et al. 2020).
This is a cross-sectional study carried out in the Basque Health Service, a public service serving
a population of just over two million inhabitants. It has 6 hospitals where babies are delivered, and
each hospital coordinates with a set of primary care centers for the monitoring of pregnancy, child­
birth and postpartum. The women were recruited between December 2019 and January 2021 by the
midwife in a pregnancy checkup in the primary care center and through snowball sampling. They were
offered the possibility of receiving the link to a questionnaire in digital format. All pregnant women
over 18 years of age who had sufficient domain of Spanish language to understand and answer the
questions presented could be included.
Informed consent was obtained from the participants prior to their participation. When the woman
accessed the link, she received information about the study characteristics, and a request for informed
consent that, when accepted, gave access to the questionnaire.

Sample size calculation

The three commonly described coping strategies (Lorén-Guerrero, Gascón-Catalán, and Romero-
Cardiel 2018; Penengo et al. 2020) were considered predictor variables for anxiety and depression.
Assuming a weak effect size (OR = 1.5), accepting an alpha risk of 0.05 and a statistical power of 0.80, it
was calculated that it was necessary to have the participation of at least 242 women. Given the type of
questionnaire to be carried out, in which the answer to all the questions was mandatory, a loss to
follow-up rate of 0 percent was estimated.

Measurement tools
The Revised Prenatal Coping Inventory (NuPCI, Hamilton and Lobel 2008) self-administered
questionnaire was used to analyze coping strategies. The questionnaire includes: an initial question
on the level of perceived stress in the pregnancy (none, some, a lot); another open question about the
reasons for stress “During this month, what has the most stressful aspect of being pregnant been for
you? Write the answer;” and 42 questions about how often they have used each coping strategy in the
last month, with four possible Likert-scale responses, from 0 (never) to 4 (very often). The items
4 I. ARTIETA-PINEDO ET AL.

mention general coping strategies, along with others that are specific to pregnancy, and are divided
into 3 scales or types of coping: a) the preparatory scale, with 15 questions, b) the avoidant coping
scale, with 11 questions and c) the spiritual coping scale, with 6 questions (Lorén-Guerrero,
Gascón-Catalán, and Romero-Cardiel 2018).
To measure anxiety, the Spanish adaptation of the state-anxiety subscale of the State-Trait Anxiety
Inventory (STAI, Spielberger 1983) was used. This is a self-assessment with 20 items and a 4-point
Likert response system according to intensity (0 = almost never/not at all; 1 = somewhat/sometimes; 2
= quite often/often; 3 = a lot/almost always). The total score ranges from 0 to 60 points, and a higher
score corresponds to a higher degree of anxiety. The 85th percentile was established as the cutoff point
for a clinically relevant score (Míguez and Pereira 2021; Vázquez and Míguez 2021).
Depression during pregnancy was measured using the Edinburgh Postnatal Depression Scale
(EPDS), whose cutoff points have been validated for pregnant women in Spain (Vázquez and
Míguez 2019). The self-assessed scale consists of 10 questions about the presence of various depressive
symptoms in the last 7 days with four response categories according to the increase in the severity of
the symptoms described. Obtaining 10 points was considered a cutoff point for the presence of
depressive symptoms (Vázquez and Míguez 2019).
Based on the literature on the subject, the possible confounding effect of other variables that could
be related to both coping ways and emotional well-being was also considered: age, parity (Goletzke
et al. 2017), nationality (Spanish/immigrant) (Yu et al. 2020), educational level (low/medium/high),
paid work (yes/no) and the presence of any previous risk factor (Giurgescu et al. 2006) (overweigh or
obesity, negative obstetric history, suffer from a physical or mental illness that requires periodic
medical supervision, be over 40 when the baby is born) with two yes/no options. Since in our country
high-risk pregnancies are supervised by the gynecologist or obstetrician, while low-risk pregnancies
are supervised by midwives, the sample only includes low-risk pregnant women. This is because the
women are selected in the midwives’ consultations.

Statistical analysis
First, a study of the metric properties of the questionnaires used in our context was carried out. Given
the ordinal nature of the items, the evaluation of structural validity was carried out by means of
confirmatory factor analysis on the polychoric correlation matrix using the diagonally weighted least
squares (DWLS) method for estimation, and reliability was quantified in terms of internal consistency
using ordinal coefficient alpha (Espinoza and Novoa-Muñoz 2018). The evaluation of the fit of the
models to the data was supported by the Chi-square/gl (χ2/gl) ratio, together with information
provided by the comparative fit (CFI) and Tucker-Lewis indices (TLI) and the absolute adjustment
indices RMSEA (Root Mean Square Error of Approximation) and its standardization (SRMS). Models
with a χ2/gl ratio of less than 5, equal to or greater than .90 in CFI and TLI and equal to or less than .10
in RMSEA and SRMS were considered acceptable.
For the study of the relationship between variables, the mean and SD were calculated in each
questionnaire to describe the continuous variables, and the absolute and relative frequencies in the
case of categorical variables. A bivariate analysis of the relationship between possible predictor
variables (sociodemographic and coping) and depression and anxiety was performed on the
established cutoff points. A logistic regression model was constructed with all the variables under
study, for each outcome variable, and the odds ratios and their 95 percent confidence intervals were
estimated. Likelihood-ratio tests (significance criterion P < .05) were used to simplify the model
following a backward strategy. Analyses were performed with SAS, version 9.4 (Cary, North
Carolina, USA).
 WOMEN & HEALTH 5

Results
341 women were offered the opportunity to participate by their midwives. Of them, 185 accepted and
answered the questionnaires. Another 96 women accessed the questionnaires based on the informa­
tion from these first women (snowball sampling). Finally, 282 (83 percent) women gave their consent
and answered all the questionnaires between weeks 8 and 41 of gestation.

Metric properties of the questionnaires

The 15 questions that make up the NuPCI questionnaire preparation scale have shown an adequate fit for
the one-dimensional theoretical model, and high internal consistency [χ2 = 323.31; p < .001; χ2/gl = 3.59;
CFI = .95; TLI = .94; RMSEA (IC90 percent) = .09 (.08–.11), SRMR = .08, αordinal = .85]. The avoidant
coping scale, made up of 11 questions, presents good metric properties [χ2 = 79.35; p = .001; χ2/gl = 1.80;
CFI = .97; TLI = .96; RMSEA (IC90 percent) = .05 (.03–.07), SRMR = .07, αordinal = .79]. Moreover, the
spiritual coping scale, with 6 questions, shows good metric function [χ2 = 9.76; p = .370; χ2/gl = 1.08;
CFI = .99; TLI = .99; RMSEA (IC90 percent) = .02 (.00–.07), SRMR = .05, αordinal = .83].
In the STAI-S anxiety questionnaire, the data has shown a good fit to the one-dimensional model,
with very high reliability [χ2 = 696.93; p < .001; χ2/gl = 4.15; CFI = .97; TLI = .97; RMSEA
(IC90 percent) = .10 (.10–.12), SRMR = .10, αordinal = .93]. Finally, the internal structure of the
EPDS depression questionnaire, showed an excellent fit to the one-dimensional model [χ2 = 80.49;
p < .001; χ2/gl = 2.44; CFI = .99; TLI = .98; RMSEA (IC90 percent) = .07 (.05–.09), SRMR = .09] and
good internal consistency (αordinal = .83).

Relationship between variables

The mean age in the sample was 33.4 years (SD 4.74). Table 1 shows the sociodemographic character­
istics of the sample and their relationship with the presence of depression and correlations between
quantitative variables.
Women were asked how often they used different kinds of coping to try to manage the strains and
challenges of being pregnant in the past month. The mean score for the preparatory-scale questions
was 2.01 (SD: 0.59); 1.08 (SD: 0.52) for the avoidant coping questions; and 1.01 (SD: 0.74) for the
spiritual coping questions. They were also asked about their perceptions of prenatal stress; low levels of
prenatal stress were reported by 43 percent (120) of women, and just 6 percent (18) reported high
levels.
In the anxiety and depression questionnaires, the subjects were divided into two groups based on
their scores in the STAI and EPDS questionnaires. The mean score on the EPDS scale was 6.43 (SD
4.31), and 68 (23.4 percent) subjects scored 10 or more in the EPDS, which was considered a positive
depression symptomatology screening, i.e., risk for a possible depressive disorder. The prevalence is
similar to that found, using the same cutoff, in the study by Vazquez MB 2019 and is somewhat lower
than that found by Míguez, Fernández, and Pereira (2017), 51 women (17.6 percent) scored from 11
and 41 (14.1 percent) from 12, which is still a high prevalence. The mean score on the STAI-S scale was
18.76 (SD 8.67), and 43 (14.7 percent) of the subjects obtained a score that was equal to or greater than
P85 (29 points), which was considered a positive anxiety screening. The bivariate analysis of the
variables under study and the results of the model adjusted for all the variables are shown in Table 2
(Model 1). The results of the final model (Model 2) of logistic regression reflected that both the
avoidant and the spiritual coping strategies showed an independent effect on the risk of suffering
a depressive symptomatology. Only the use of avoidant coping strategies increased the likelihood of
clinically detectable anxiety (Figure 1-up). Moreover, pregnant women who already have at least one
child are more likely to suffer from both anxiety and depressive symptomatology during pregnancy
(Figure 1-down).
6 I. ARTIETA-PINEDO ET AL.

Table 1. Characteristics of the sample and their relationship with the presence of depression (score ≥ 10) and anxiety (score ≥ 29) as
clinical entities.
Depression Screening (EPDS) Anxiety Screening (STAI-S)

Total n (%) Positive Negative p-value Positive Negative p-value

Avoidant coping <.001 <.001
Mean (SD) 1,1 (0,52) 1,47 (0,48) 0,99 (0,48) 1,54 (0,44) 1,02 (0,49)
Preparatory Coping .11 .264
Mean (SD) 2,02 (0,59) 2,12 (0,58) 1,99 (0,59) 2,12 (0,58) 2 (0,59)
Spiritual Coping .009 .677
Mean (SD) 1,01 (0,74) 1,25 (0,85) 0,94 (0,69) 1,05 (0,68) 1 (0,75)
Age .602 .702
<30 49 (16,7) 14 (20,6) 35 (15,8) 5 (11,6) 44 (17,7)
30–34 126 (43) 30 (44,1) 95 (42,8) 18 (41,9) 108 (43,4)
35–39 86 (29,4) 19 (27,9) 65 (29,3) 15 (34,9) 70 (28,1)
≥40 32 (10,9) 5 (7,4) 27 (12,2) 5 (11,6) 27 (10,8)
Weeks of gestation .348 .236
<28 106 (36,2) 25 (36,8) 79 (35,6) 13 (30,2) 92 (36,9)
28–37 138 (47,1) 28 (41,2) 109 (49,1) 19 (44,2) 119 (47,8)
>37 49 (16,7) 15 (22,1) 34 (15,3) 11 (25,6) 38 (15,3)
Parity .005 .02
Primiparous 205 (70,4) 38 (57,6) 167 (75,2) 24 (55,8) 181 (73,3)
Multiparous 86 (29,6) 28 (42,4) 55 (24,8) 19 (44,2) 66 (26,7)
Nationality .167 .784
Spanish 256 (87,4) 56 (82,4) 197 (88,7) 37 (86) 218 (87,6)
Foreign 37 (12,6) 12 (17,6) 25 (11,3) 6 (14) 31 (12,4)
Educational level .036 .336
Up to Secondary 33 (11,4) 10 (15,2) 22 (10) 5 (12,2) 28 (11,3)
Secondary/F.E. 107 (37) 31 (47) 75 (34,1) 19 (46,3) 87 (35,2)
Graduates 149 (51,6) 25 (37,9) 123 (55,9) 17 (41,5) 132 (53,4)
Paid work .759 .411
Yes 208 (73,5) 51 (75) 155 (73,1) 33 (78,6) 174 (72,5)
No 75 (26,5) 17 (25) 57 (26,9) 9 (21,4) 66 (27,5)
Perceived stress in the pregnancy .003 <.001
None 142 (50,7) 21 (32,8) 121 (56) 7 (17,9) 135 (56)
Some 120 (42,9) 36 (56,2) 84 (38,9) 25 (64,1) 95 (39,4)
A lot 18 (6,4)) 7 (10,9) 11 (5,1) 7 (17,9) 11 (4,6)
Correlations between quantitative variables
Avoidant Preparatory Spiritual Weeks of gestation
EPDS STAI-S coping Coping Coping Age
EPDS 1.00
STAI-S 0.642 1.00
Avoidant coping 0.467 0.457 1.00
Preparatory 0.177 0.076 0.315 1.00
Coping
Spiritual Coping 0.179 0.099 0.164 0.227 1.00
Age −0.080 0.013 −0.096 −0.22 −0.343 1.00
Weeks of gestation 0.122 0.115 0.204 0.258 0.033 −0.074 1.00
*Significant differences (p < .05) and correlations between quantitative variables.

Discussion
Regarding the study of the psychometric properties of the NuPCI, the EDPS and the STAI in our study, it
is noteworthy that: 1) the psychometric characteristics of the NuPCI are even better than those found
in a study previously carried out in a Spanish population only from the exploratory perspective
(Lorén-Guerrero, Gascón-Catalán, and Romero-Cardiel 2018). In addition, the sample used in our
study includes women of all gestational stages, unlike the one used in the previous study, which was
only made up of women who had just given birth, which entails serious limitations for the general­
ization of the results. 2) In the case of the EDPS, there is no previous study that has evaluated the
internal structure and reliability of the questionnaire in our context. There were adaptations in
 WOMEN & HEALTH 7

Table 2. Model 1: regression analysis of the coping strategy and of the sociodemographic variables in the presence of a positive score
in the depression (EPDS) and Anxiety (STAI-S) screening test. Model 2: predictive variables of a positive score in the Depression
(EPDS) and Anxiety (STAI-S) screening tests during pregnancy after eliminating the sociodemographic and coping variables with
lesser contribution to the regression model.
Depression (EPDS) Anxiety (STAI-S)

OR* CI (95 percent) p-value** OR CI (95 percent) p-value

Model 1
Avoidant coping 8.66 4.17–19.3 <.001 8.67 3.8–21 <.001
Preparatory coping 1.12 0.61–2.06 .715 1.17 0.6–2.3 .656
Spiritual coping 1.88 1.05–3.39 .033 0.98 0.5–1.9 .942
Age .838 .264
<30 ref ref
30–34 1.52 0.52–4.82 .458 1.87 0.5–8.8 .393
35–39 1.43 0.41–5.23 .576 3.87 0.9–21 .091
≥40 1.04 0.22–4.63 .96 3.57 0.6–23 .162
Weeks of gestation .864 .691
<28 ref ref
28–37 1.24 0.57–2.77 .597 1.36 0.5–3.6 .528
>37 1.08 0.4–2.87 .881 1.57 0.5–4.7 .417
Parity <.001 .03
Primiparous ref ref
Multiparous 4.92 2.21–11.4 2.67 1.1–6.6
Nationality .442 .681
Spanish ref ref
Foreign 0.63 0.19–2 1.32 0.3–4.8
Educational level .083 .332
Up to secondary ref ref
Secondary/F.E. 0.54 0.18–1.69 .284 1.41 0.4–7.2 .642
Graduates 0.29 0.09–0.96 .039 0.74 0.2–3.9 .693
Paid work .386 .553
Yes ref ref
No 0.7 0.3–1.55 0.76 0.3–1.9
Risk factors .243 .28
No ref ref
Yes 1.54 0.75–3.22 1.59 0.7–3.8
Model 2
Avoidant coping 8.29 4.24–17.4 <.001 8.88 4.26–20.1 <.001
Spiritual coping 1.67 1.09–2.56 .018
Parity <.001 .002
Primiparous ref ref
Multiparous 4.1 2.04–8.53 3.41 1.58–7.5
*OR adjusted for all sociodemographic and coping variables.
**Significant differences (p < .05).

Spanish used in North America with Spanish speakers and tested in Chile (Alvarado et al. 2015), but
not in Spain. We now have evidence about the proper functioning of this tool in pregnant Spanish
women. 3) Finally, the STAI was chosen because it is one of the most widely used tests for the
assessment of anxiety during pregnancy. In the present study the format used is digital and it is seen
that it continues to maintain its good psychometric properties.
On the other hand, the results of this study show that the most preferred coping strategy used is
preparedness. However, our results do not indicate that preparatory coping is associated with a lower
occurrence of depressive symptoms and distress. It should be noted that the preferential use of avoidant
coping strategies does associate with the presence of depressive or anxiety symptoms, reaching pathology
criteria; moreover, this relationship is observed independently of all the sociodemographic variables
studied. The findings could point in the same direction as some previous research (Balsom and
Gordon 2021; Guardino and Dunkel Schetter 2014; Ibrahim and Lobel 2020; Penengo et al. 2020),
which suggest that avoidant coping preference in low-risk pregnancy may be a mediating variable
between the anxiety often generated by the prospect of childbirth and becoming a mother, and a non-
adaptive or even pathological response a posteriori (Peñacoba Puente et al. 2021).
8 I. ARTIETA-PINEDO ET AL.

Figure 1. Relationship between the score in each coping style (avoidant, preparatory and spiritual) and the score in depression
(EPDS) and Anxiety (STAI-S) and, between parity (primiparous vs. one or more children) and “positive” score in depression and
Anxiety screening.

Some studies found that problem-focused coping styles, such as problem solving, planning and
preparation, are associated with greater pregnancy-related distress, whereas others found that active
coping styles were associated with fewer depressive symptoms or null effects (Gourounti,
Anagnostopoulos, and Lykeridou 2013; Lau, Wang, and Kwong 2015). Perhaps the lack of statistical
association between preparatory coping and lower pathology may be due to the fact that for women
with a low-risk pregnancy, the use of active planning and preparation strategies constitutes the usual
behavior (Lorén-Guerrero, Gascón-Catalán, and Romero-Cardiel 2018; Penengo et al. 2020; Yu et al.
2020). In fact, the result of this work shows that the mean score is higher on the preparedness coping
scale, and that most women show this form of coping as predominant. It could also be considered that
avoidance strategies are not the opposite of preparedness strategies, but the deviation from the normal.
Therefore, attention should be paid, in prenatal care consultations, when the woman presents
 WOMEN & HEALTH 9

a predominant use of avoidant coping, and treat it as a risk factor for the appearance of psychological
alterations, such as a state of pathological anxiety or depression. The evidence regarding spiritual
coping is less conclusive, since while some authors find an association with emotional distress,
(González-Mesa et al. 2018) others point to it as a protective strategy (Faramarzi et al. 2020). The
discrepancy may be due to differences in the spiritual experience of different people and cultures, and
while in some cases, trust in a higher being can be reassuring, in others, spirituality (e.g. praying) can
resemble a cognitive rumination strategy.
On the other hand, although it seems reasonable to expect that previous experience will lead to
a greater sense of control and less distress (Schwartz et al. 2015), women of our population who
already have at least one child, are more likely to suffer from both anxiety and depressive symptoma­
tology during pregnancy. It is very frequent in the literature to find higher levels of anxiety and
depression in multiparous women (Goletzke et al. 2017). This is often attributed to the need to care for
another child and more family worries and obligations (Ghasemi et al. 2018). But it is also possible that
the higher levels of anxiety and depression during pregnancy are related to previous bad experiences,
or to the perception that the preparatory strategies used previously have not been helpful; there could
be a kind of learned helplessness in these women, who fear the lack of control of the situation once
they arrive at the hospital to give birth. Some authors highlight this impossibility (Kahalon et al. 2020).
To conclude, there are clinical implications that warrant discussion. The association of an avoidant
coping style with pathological levels of anxiety and depression indicates the advantage of identifying
the coping strategies of women during pregnancy. Women with high avoidant coping scores could
benefit from personalized training in cognitive behavioral techniques (Felder et al. 2020; Mcmillan
et al. 2010; Molgora, Fenaroli, and Saita 2020), such as gradual exposure to different moments in the
evolution of labor and parenting (Bayrampour et al. 2015), training in problem-solving techniques
(Guardino and Dunkel Schetter 2014), restructuring negative thoughts, distraction training, real
practice of appropriate behaviors, search for social cohesion and family support (Lau et al. 2016;
Molgora, Fenaroli, and Saita 2020) and relaxation techniques. The indiscriminate application of these
techniques may not be beneficial for women who already have their own positive strategies
(Ockhuijsen et al. 2014). In this regard, new technologies offer the potential to explore women´s
strategies continuously and individually, allowing follow-up and self-evaluation (Bayrampour, Trieu,
and Tharmaratnam 2019; Felder et al. 2020; Lau et al. 2021). These techniques could be complemented
with face-to-face care in the most complex cases.
This study has some limitations, Such as the impossibility of establishing a cause-effect relationship,
as it is a correlational study. It is likely that there is a two-way relationship (Hamilton and Lobel 2008),
since the avoidance of a problem can increase anxiety, which in turn will favor a greater use of
avoidance (Gourounti, Anagnostopoulos, and Lykeridou 2013). Moreover, it is possible that
in situations of uncertainty, the use of strategies oriented to the problem can lead to frustration
(Gourounti, Anagnostopoulos, and Lykeridou 2013; Guardino and Dunkel Schetter 2014; Giurgescu et
al. 2006). Another possible limitation could derive from the cross-sectional nature of the study. Since
a coping style can initiate in the culture (Yu et al. 2020) and come from early learning, a longitudinal
study would allow us to see changes throughout pregnancy and postpartum. Additionally, the fact that
the study was conducted during the period of the global pandemic by COVID-19 could be seen as
a limitation, as it could influence anxiety and depression scores. Given the cross-sectional nature of the
study, it is certainly not possible to know how much it may have influenced; this is why we analyzed
the mean anxiety and depression scores and compared them with normative data obtained before
COVID for general population (Buela-Casal, Guillén-Riquelme, and Seisdedos 2011) and for pregnant
women (Vázquez and Míguez 2019), and found no significant differences.

Summary of the conclusions

The results show that the higher the score on the avoidance subscale, the higher the likelihood of
having an anxiety disorder and depressive symptoms. Multiparous women are more likely to have
10 I. ARTIETA-PINEDO ET AL.

anxiety or depressive symptomatology during pregnancy. These results highlight the need to consider
the evaluation of CS used during pregnancy to tailor the care provided, but further studies on the
implementation and effectiveness of interventions are needed.

Acknowledgments
We would like to thank all pregnant women who have responded to the questionnaires in this study and the midwives;
Sonia Alvarez, Pilar Amorrortu, Mónica Blas, Inés Cabeza, Itziar Estalella, Ana Cristina Fernández, Gloria Gutiérrez de
Terán-Moreno, Kata Legarra, Gorane Lozano, Amaia Maquibar, David Moreno-López, María Jesús Mulas, Covadonga
Pérez, Angela Rodríguez, Mercedes Sáenz de Santamaría, Jesús Sánchez and Gema Villanueva, who have carried out the
recruitment work on behalf of the ema-Q group.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
We appreciate the grant received by the Institute of Health Carlos III, file number PI20/00899, within the State R&D&I
Plan 2017–2020 and co-financed by the ISCII – Subdirectorate – General Evaluation and Promotion of Fund Research
European Regional Development Fund (FEDER). This study has been co-financed by the Basque Government
Department of Health [File n°: 2018111087], and its realization has been possible thanks to the management of the
Biocruces-Bizkaia Health Research Institute.

ORCID
Isabel Artieta-Pinedo RN, CNM, PhD http://orcid.org/0000-0002-4297-2495
Carmen Paz-Pascual RN, CNM http://orcid.org/0000-0001-9170-0667
Maite Espinosa MD http://orcid.org/0000-0003-4886-3270
Arturo García-Alvarez MD http://orcid.org/0000-0001-8481-0104
the ema-Q Group http://orcid.org/0000-0002-4511-1412
Paola Bully MD http://orcid.org/0000-0002-9304-1068

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