JOURNAL JOURNAL OF PUBLIC OF PUBLIC HEALTH, HEALTH, NURSING NURSING AND AND MEDICAL MEDICAL RESCUE RESCUE No.4/2013 No.4/2013 (37-42) 37 The inensificaion of sress in regnan women wih risk of reerm delivery (Nasilenie sresu u kobie ciężarnych z zagrażającym orodem rzedwczesnym) M Sulima 1 A,D,F, M Lewicka 1 D, M Makara Sudzińska 2 E, K Wikor 3 B, H Wikor 1 C Absrac - Inroducion. Women whose regnancy is hreaened by he risk of a remaure delivery ofen require hosialisaion. In such cases, hey have o face u o dual sress ha relaed o regnancy and hosialisaion as well. The urose of he aer. The aim of his aer was o assess he sress level in regnan women hosialised because of he risk of reerm delivery. Maerials and mehods. The sudy involved 313 women who were hosialised and reaed because of he risk of reerm delivery beween he 23 rd and 37 h week of regnancy. The sudy was conduced using a survey develoed by he auhors (o deermine he characerisics of he sudy grou) as well as a sandardised research ool he Perceived Sress Scale (-10). The risk of non sequiur was assumed o be 5%, while <0.05 was considered saisically significan. Resuls. The mean sress level in he sudied aiens over 30 years of age was significanly lower (=0.04) han in he age grou of below 25. Wha is more, he sudy has shown ha he sress level was significanly lower (=0.02) in he case of women who had higher (eriary) educaion as comared o hose who had secondary or rimary educaion. Also, significanly lower (=0.002) sress level was observed in married as oosed o unmarried women. The mean sress level in he grou of women wih singleon regnancy was significanly higher (=0.02) han in he case of mulile regnancies. Conclusions. There is a need o ake effecive sychorohylacic and sychoheraeuic measures aimed a minimising he sress of hosialised regnan women, esecially hose unmarried, u o 25 years old, wih rimary or vocaional educaion and singleon regnancies. Key words - regnan women, he risk of reerm delivery, sress, hosialisaion. Sreszczenie Wsę. Kobiey, kórych ciąża zagrożona jes orodem rzedwczesnym, częso wymagają hosializacji. Jes o dla nich wydarzenie obciążające, w kórym kobiea jes odmioem oddziaływania dualnego sresu ciąży oraz hosializacji. Cel racy. Celem racy była ocena oziomu sresu w gruie kobie ciężarnych hosializowanych z owodu zarażającego orodu rzedwczesnego. Maeriał i meody. Badaniami objęo 313 kobie, kóre były hosializowane leczone z owodu zagrażającego orodu rzedwczesnego omiędzy 23. a 37. ygodniem ciąży. Badania rzerowadzono z zasosowaniem kwesionariusza ankiey własnego auorswa oracowanego do usalenia charakerysyki badanych ciężarnych oraz sandaryzowanego narzędzia badawczego- Skali Odczuwanego Sresu (Perceived Sress Scale -10). Przyjęo 5% ryzyko błędu wnioskowania, <0,05 uznano za isone saysycznie. Wyniki. Warość średnia oziomu sresu w gruie badanych w wieku owyżej 30 la była isonie mniejsza (=0,04) aniżeli wśród badanych w wieku do 25 la. Ponado badania wykazały, oziom sresu był isonie niższy (=0,02) u kobie ciężarnych osiadających wykszałcenie wyższe aniżeli u ciężarnych, kóre osiadały wykszałcenie odsawowe lub zawodowe. Isonie mniejsze (=0,002) nasilenie sresu zaobserwowano w gruie badanych zamężnych w orównaniu do badanych niezamężnych. Średnia warość oziomu sresu w gruie kobie ciężarnych, u kórych swierdzono ciążę ojedynczą była isonie większa (=0,02) od średniej warości oziomu sresu w gruie badanych, u kórych swierdzono ciążę mnogą. Wnioski. Isnieje orzeba odjęcia skuecznych kierunków działań sychorofilakycznych i sychoeraeuycznych zmierzających do zminimalizowania sresu szczególnie w odniesieniu do ciężarnych w wieku do 25 la, osiadających wykszałcenie odsawowe lub zawodowe, niezamężnych, z ciążę ojedynczą. Słowa kluczowe - kobiey ciężarne, zagrażający oród rzedwczesny, sres, hosializacja. Auhor Affiliaions: 1. Dearmen of Obserics, Gynaecology and Obserical - Gynaecological Nursing, Faculy of Nursing and Healh Sciences, dical Universiy of Lublin. 2. Dearmen of Alied Psychology, Faculy of Nursing and Healh Sciences, dical Universiy of Lublin. 3. Chair and Dearmen of Gynaecology and Gynaecological Endocrinology, Faculy of Nursing and Healh Sciences, dical Universiy of Lublin. Auhors conribuions o he aricle: A. The idea and he lanning of he sudy B. Gahering and lising daa C. The daa analysis and inerreaion
JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/2013 38 D. Wriing he aricle E. Criical review of he aricle F. Final aroval of he aricle Corresondence o: Magdalena Lewicka MD, PhD, Dearmen of Midwifery, Gynaecology and Gynaecological Nursing; Faculy of Nursing and Healh Sciences, dical Universiy of Lublin, Chodźki 6 Sr., PL-20-093 Lublin, Poland, e-mail: m.lewicka@umlub.l S I. INTRODUCTION ress accomanies human life ever since is very beginning and consiues is inescaable ar. Three basic definiions of sress can be encounered in academic lieraure. Sress is ofen described wih reference o secific evens aking lace in he surroundings, which rigger he feelings of ension and nervousness. According o his incenive-based heory, sress is a secific reacion o simuli in he environmen. Sress can also be defined as a reacion o a sressful siuaion; in his view he emhasis is u on he hysiological and sychological asecs of he even. These reacions are generally similar regardless of he simulus ha has roduced hem. Therefore, he consensus is ha relevan informaion on sress can be colleced on he basis of he reacion of he organism raher han he even ha has caused sress. The hird conemorary undersanding of sress is he assumion ha sress includes boh sressful exeriences and he sychological and hysiological reacions o hem. This aroach inroduces he sychological asec ha sees sress as a ranslocaion beween an individual and he environmen, in which he erson has o evaluae he siuaion a hand and resources ha are available o coe wih i [1,2]. A crucial ar in he sress-induced reerm deliveries is layed by he remaure acivaion of he hyohalamiciuiary-adrenal axis. The imac of he growh in he roducion of coricoroin-releasing hormone (CRH, secreed by he rohoblas and lacena), adrenocoricoroin (ACTH secreed by he iuiary) and glycocoricoids (secreed by he adrenals and regulaing he CRH level in he lacena as well as simulaing he roducion of rosaglandins) on he rocess is believed o be vial. The increased level of he CRH simulaes he biosynhesis of DHEA in he adrenals of he foeus a subsrae o he roducion of oesrogens. The remaure increase in corisol and oesrogen levels in he ineracion wih rosaglandins and oxyocin leads o remaure sysolic funcion of he uerus [3,4,5]. According o he heory develoed by Lazarus [6], regnancy causes sychological sress. Desie he fac ha a regnancy is a osiive change in a woman s life, i is he 12 h criical life even on he Holmes and Rahe sress scale. Pregnancy is relaed o frusraion (wih needs and lans ha canno be saisfied or fulfilled, e.g. career lans) and causes a range of inernal conflics, e.g. wheher o coninue working or ake a leave. Furhermore, i is a source of individual and social ressure (will I be a erfec moher?). The diagram of a regnan woman s sress inensiy looks like a sinusoid. The firs eak comes when he regnancy is diagnosed, afer which a woman slowly adas o he siuaion. Then, deending on how he regnancy is rogressing, he sress level flucuaes. The eak of he sress inensiy comes in he anearum eriod. The risk of reerm delivery, he need o be hosialised and he ossibiliy of having a remaure baby lead o he regnan woman s higher sress level [7,8,9,10]. The urose of his aer was o assess he sress level in regnan women hosialised because of he risk of reerm delivery. II. MATERIALS AND METHODS The sudy involved 313 regnan women who were hosialised and reaed because of he risk of reerm delivery a he Gynaecology and Obserics Dearmen of he Cardinal Sefan Wyszyński Secialis Hosial and he Chair and Dearmen of Obserics and Perinaology of he dical Universiy of Lublin during he eriod beween Ocober 2010 and March 2012. The sudy was conduced afer The Bioehics Commiee of he dical Universiy of Lublin aroved of i. Women who were hosialised and reaed because of he risk of reerm delivery beween he 23 rd and 37 h week of regnancy and had no hisory of menal disurbances were qualified for he sudy. All he regnan women who ook ar in he sudy volunarily and consciously consened o do so. Each of he quesionnaires he women were handed included: an auhorial survey develoed in order o deermine he characerisics of he sudied women and a sandardized research ool he Perceived Sress Scale (-10). -10 was develoed by S. Cohen, T. Kamarck and R. rmelsein. The auhors of he Polish version are Z. Juczyński and N. Ogińska-Bulik. The -10 scale is used o measure he inensiy of osiive and negaive emoions relaed o one s own siuaion in life over he las monh. Is urose is o deec curren emoional saes as well as ermanen affecive feaures. -10 is a self-descriion ool ha includes 10 quesions. This es can be erformed boh on individual and grou basis, regardless of wheher he aiens are healh or sick. In order o obain a general indicaor of he sress exerienced, he numerical values secified by he inerviewee
JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/2013 39 are added u. The score may be wihin he range of 0-40; he higher i is, he greaer he sress inensiy. Then, he resuls are recalculaed using a sen score. Scores beween 1 and 4 indicae low sress inensiy, beween 5 and 6 medium sress inensiy and 7 o 10 high sress inensiy. The resul obained on he is an indicaor of he assessmen of one s own siuaion in life as sressful. i.e. unforeseeable, unconrollable and excessively burdensome. The basis for comarison is rovided by he normalised resuls. is characerised by saisfacory sychomeric arameers. The inernal consisency deermined on he basis of Cronbach s alha is 0,85 [11]. The sudy of he characerisics of he aiens inerviewed showed ha 62 regnan women (19.81%) were 25 or younger, 137 of hem (43.77%) were in he age grou of 26 o 30 and 114 (36.42%) were over 30. 24 of hem (7.67%) had rimary or vocaional educaion, 79 (25.24%) had secondary educaion and 210 of hem (67.09%) had eriary educaion. Among he regnan women sudied, 285 (91.05%) were married and 28 (8.95%) were unmarried. 131 of he aiens (41.85%) lived in rovincial caials, 86 (27.47%) inhabied couny owns and 96 of hem (30.67%) lived in he counry. 104 of he regnan women (33.22%) saed ha heir living and housing condiions were very good, 162 (51.75%) considered hem good and 46 (14.69%) claimed hey were moderae. 1 erson (0.31%) admied having bad living and housing condiions. Ou of 313 (100%) regnan women hosialized due o he risk of reerm delivery, 151 (48.24%) were regnan for he firs ime, 99 (31.63%) for he second ime and 40 (12.78%) for he hird ime. For 23 (7.35%) sudied women i was a leas a fourh regnancy. 246 of he aiens (78.59%) claimed heir regnancy was a lanned one, while 67 (21.41%) claimed hey did no lan he curren regnancy. Singleon regnancies were he case in 299 (95.53%) resondens, whereas 14 women (4.47%) had a mulile regnancy. 60 of he sudy grou (19.17%) were beween he 23 rd and 27 h week of he regnancy, 103 (32.91%) were 28 o 32 weeks along. For 150 of hem (47.92%), i was a 33 rd o 37 h week. Table 1. The resuls of he sress level analysis () deenden on he sociodemograhic variables Age 25 or less (I) 26 30 (II) over 30 (III) Educaion rimary / vocaional (I) secondary (II) eriary (III) Marial saus 62 18.94 6.86 6.00 34.00 17.50 I II 1.08 137 17.80 6.87 3.00 36.00 17.00 I III 2.08 II III 1.10 114 16.89 5.86 2.00 31.00 16.00 24 20.50 7.22 10.00 33.00 19.00 I II 0.28 0.04* 0.27 1.31 79 18.56 6.07 6.00 33.00 18.00 I III 2.42 II III 1.78 210 17.05 6.54 2.00 36.00 16.00 married 285 17.34 6.36 2.00 36.00 16.00 unmarried 28 21.29 7.34 9.00 34.00 21.00 Place of residence 0.19 0.02* 0.08-3.09 0.002* III. RESULTS rovincial caial (I) 131 16.89 I II 6.74 2.00 36.00 16.00 I III 1.45 1.64 II III -0.04 0.15 0.10 0.97 The mean values of sress indicaor recorded in he quesionnaire show ha he sress inensiy in he sudied grou of regnan women hosialised because of he risk of reerm delivery. Table 1 shows he resuls of he sress level analysis () deenden on he sociodemograhic variables. The mean sress level in he grou of women over 30 years of age was significanly lower (=0.04) han among he women of 25 or less. In urn, he value for he 26-30 grou was 17.80 and no saisical significance was observed here (>0.05) as comared o he grous of 25 or less and over 30. Wha is more, he sudy has shown ha educaion also influenced he sress level, as i was significanly lower
JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/2013 40 (=0.02) among regnan women who had higher (eriary) educaion han in he case of hose wih rimary or vocaional educaion. The inensiy of sress was also si g- nificanly lower (=0.002) in he grou of married women (17.34) han among hose unmarried (21.29). No saisically significan differences (>0.05) were observed in relaion o he lace of residence. Table 2. The sress inensiy agains he daa on he aricular regnancy The analysis of he sress inensiy agains he daa on he aricular regnancy is shown in Table 2. On he basis of he auhors sudy i was observed ha he number of regnancies, week of regnancy and wheher or no he regnancy was lanned did no have imac on he sress level in he sudy grou (>0.05). Neverheless, i was observed ha he mean sress level of women wih singleon regnancies (17,89) was significanly higher (=0,02) han among hose wih mulile regnancies (13.57). Number of regnancies firs (I) 151 17.53 6.44 6.00 36.00 16.00 second (II) 99 17.73 7.01 2.00 33.00 17.00 hird (III) 40 18.80 6.02 8.00 30.00 20.00 a leas fourh (IV) Planned regnancy 23 16.70 6.10 4.00 30.00 14.00 Yes 246 17.34 6.57 2.00 36.00 16.00 No 67 18.99 6.33 6.00 33.00 19.00 Tye of regnancy singleon regnancy mulile regnancy Week of regnancy 299 17.89 6.45 2.00 36.00 17.00 14 13.57 7.26 3.00 27.00 15.00 I II I III I IV II III II IV III IV 23 27 (I) 60 18.65 6.96 4.00 33.00 17.00 I II 28 32 (II) 103 17.90 6.71 6.00 36.00 17.00 33 37 (III) 150 17.17 6.24 2.00 30.00 16.00-0.23 0.82-1.12 0.26 0.58-0.85 0.65 1.33-1.83 0.07-2.43 0.02* I III II III 0.68 1.51 0.89 0.56 0.38 0.52 0.19 0.50 0.13 0.37 IV. DISCUSSION Women whose regnancies are hreaened by a remaure birh ofen require hosialisaion. Such circumsances are oressive for hem, as hey need o coe wih wo kinds of sress relaed o boh he regnancy and hosialisaion. The sress exerienced by hosialised regnan women is relaed o saying a he hosial, aking medicines, roblems wih esablishing relaionshis wih medical saff and oher aiens, weakness relaed o immobiliy and lack of aciviy, searaion from he family, longing for he husband and children, worrying if he res of he family would be fine a home wihou her [12,13,14,15]. Alhough he rogress in medical science gives one he ooruniy o give birh o a healhy child, regnan women hardly acknowledge ha on heir emoional level, which is why i barely modifies heir emoional exeriences and does no rigger a dro in he sress level [16]. The lieraure available offers few analyses of he sress level among regnan women who were hosialised because of he risk or reerm delivery. Semczuk e al. [16] sudied he sychological sress in he cases of high-risk regnancies. This sudy was conduced among 50 aiens of dical Universiy of Lublin s Clinics. dical diagnoses of he women were: imminen aborion (N=14), remaure birh (N=18) and chronic diseases hyerension or diabees (N=18). The mean values obained indicaed moderae sress inensiy in all he clinical grous. I is he auhors observaion ha a regnancy a risk is he cause of sychological sress, while he srucure and inensiy of he sress is deenden on he ye of he risk. Kraczkowski e al. [17] believe a high-risk regnancy is relaed o exeriencing emoional conflics, which reflec he emoional ension and he imbalance beween a woman s execaions owards herself as a moher and he hrea over he child s life. The resuls of he sudy by hese auhors, which involved 65 women hosialised because of a high-risk regnancy, indicaed a higher level of regnancy-relaed sress as well as greaer focus on he condiion of he regnancy, which in urn significanly increased he emoional ension. Kossakowska-Perycka and
JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/2013 41 Walęcka-Mayja [18], on he basis of heir sudy among women wih high-risk regnancies (imminen aborion, remaure birh, moher s illness), observed ha he sress level was higher (M=23.49) han among he women whose regnancies were no a risk (M=21.09). The sudy by he auhors of he curren aer showed ha regnan women hosialised because of he risk of reerm delivery has moderae level of sress inensiy (17.69). This level migh resul from he fac ha he women involved in he sudy had aroriae knowledge on he rogress in medical science which gives one an ooruniy o susain he life of remaure babies. The sudy resuls obained indicae ha deermining he level of sress among regnan women hosialised because of a risk of reerm delivery should be considered an imoran elemen of he diagnosis by docors and nurses, as i allows hem o idenify he aiens requiring secial aenion as far as aking sychorohylacic measures is concerned. This oinion is shared by oher auhors [19,20]. V. CONCLUSIONS 1. Pregnan women hosialised because of he reerm delivery risk are characerised by moderae sress level. 2. A woman s age, educaion, marial saus and he ye of regnancy (singleon or mulile) are facors influencing he sress level among he regnan women hosialised due o he risk of reerm delivery. On he oher hand, heir lace of residence, number of regnancies and he week of regnancy do no have a significan imac on he sress level. 3. There is a need o ake effecive sychorohylacic and sychoheraeuic measures aimed a minimising he sress of hosialised regnan women, esecially hose unmarried, u o 25 years old, wih rimary or vocaional educaion and singleon regnancies. VI. REFERENCES [1] Heszen I, Sęk H. Zdrowie i choroba w aradygmacie sresu sychologicznego. Psychologia zdrowia. Warszawa; Wydawnicwo Naukowe PWN, 2008. [2] Heszen, I, Sęk H. Zdrowie i sres. W: Psychologia. Podręcznik akademicki. Tom 2. Srelau J, Doliński, D (red). Gdańsk; Gdańskie Wydawnicwo Psychologiczne, 2008. [3] Alderdice F, Lynn F. Facor srucure of he Prenaal Disress Quesionnaire. Midwifery 2011; 27: 553 559. [4] Davis EP, Sandman CA. Prenaal exosure o sress and sress hormones influences child develomen. Infan Young Child; 2006, 19 (3): 246 259. [5] Giurgescu C. Are maernal corisol levels relaed o reerm birh. I Obse Gynecol Neonaal Nurs; 2009, Jul-Aug; 38 (4): 377 390. [6] Krzyżanowska-Zbucka J. Problemy emocjonalne kobie w okresie okołoorodowym. Warszawa; Fundacja Rodzić o Ludzku, 2008. [7] Sosa C, Alhabe F, Belizán J.M, Bergel. E. Bed res in singleon regnancies for revening reerm birh (review). Cochrane Daabase Sys Rev; 2004, 1: 1 13. [8] Basani F, Hidarnia A, Kazemnejad A e al. A Randomized Conrolled Trial of he Effecs of Alied Relaxaion Training on Reducing Anxiey and Perceived Sress in Pregnan Women. J Midw & Women s Healh; 2005, Jul-Aug; 50 (4): 36 40. [9] Bąk-Sosnowska M. Psychologiczne aseky ciąży i macierzyńswa. W: Psychologia. Podręcznik dla sudenów kierunków medycznych. Trzecieniecka-Green A(red). Kraków; Wydawnicwo Universiais, 2006. [10] Cardwell MS. Sress: regnancy consideraions. Obse Gynecol Surv; 2013, 68 (2): 119-129. [11] Juczyński Z, Ogińska-Bulik N. Narzędzia omiaru sresu i radzenia sobie ze sresem. Warszawa; Pracownia Tesów Psychologicznych, PTP, 2009. [12] Breen GV, Price S, Lake M. Siriualiy and high-risk regnancy: anoher asec of aien care. AWHONN Lifelines; 2007, Dec-Jan; 10 (6): 466 473. [13] Danerek M, Dykes AK. A heoreical model of arens exeriences of hrea of reerm birh in Sweden. Midwifery; 2008, 24 (4): 416 424. [14] Maloni JA. Lack of evidence for rescriion of anearum bed res. Exer Rev of Obse Gynecol; 2011, 6 (4): 385 393. [15] Weidner K, Biner A, Junge-Hoffmeiser J e al. A sychosomaic inervenion in regnan in-aien women wih renaal somaic risks. J Psychosom Obse Gynaecol; 2010, Se; 31 (3): 188 198. [16] Semczuk M, Seuden S, Szymona K. Ocena nasilenia i srukury sresu u rodziców w rzyadkach ciąży wysokiego ryzyka. Ginekol Pol; 2004, 75 (6): 417 424. [17] Kraczkowski J, Szymona-Pałkowska K, Krzyżanowski A e al. Analiza orównawcza doświadczanego sresu u kobie z ciążą wysokiego ryzyka i ciążą fizjologiczną. XXIX Kongres Polskiego Towarzyswa Ginekologicznego, Ginekol Pol; 2006, 1: 42-48. [18] Kossakowska-Perycka K, Walęcka-Mayja K. Psychologiczne uwarunkowania wysaienia deresji oorodowej u kobie w ciąży o rzebiegu rawidłowym i ciąży wysokiego ryzyka. Ginekol Pol; 2007, 78: 544 548. [19] Szymańczak G, Lishchynskyy Y, Kozłowska D, Koański Z, Bruchwicka I, Wojciechowska M. Psychosołeczne roblemy samobójsw. JPHNMR; 2012 (1):20-22.
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