Impact of Prenatal Cognitive-Behavioral Stress Management Intervention on Maternal Anxiety and Depression and Newborns’ Apgar Scores

Document Type: Original Article


Department of Psychology , Shahid Bahonar University of Kerman, Kerman, Iran


Background: Motherhood is a transformative and pleasing experience in a woman’s life. However, given the physical and psychological changes, it can induce a degree of stress and anxiety in mothers. The aim of the present study was to evaluate the effects of cognitive-behavioral stress management (CBSM) on maternal anxiety and depression during pregnancy and newborns’ Apgar scores.
Methods: This semi-experimental study was performed by applying a pretest-posttest control-group design. Overall, 30 primiparous mothers were selected among women referring to health clinics of Kerman, Iran, using convenience sampling. Subjects were randomly allocated to experimental and control groups. Data were collected, using Pregnancy-Related Anxiety Questionnaire and Edinburgh Postnatal Depression Questionnaire. After completing the pretest, the experimental group was subjected to 12 sessions of CBSM training; posttest data were collected after the intervention. Multivariate analysis of covariance was performed, using SPSS version 16. P-value < 0.05 was considered statistically significant.
Results: The obtained results revealed a significant decrement in the average posttest scores of anxiety and depression in the experimental group, compared to pretest scores and the control group. Moreover, differences in 1- and 5-minute Apgar scores between the two groups were statistically significant. These findings indicated the effectiveness of CBSM during pregnancy in reducing maternal anxiety and depression.
Conclusion: Pregnant women can benefit from psychological interventions such as CBSM in medical and health care centers.


1-   Da Costa, D., Larouche Dritsa, M., & Brender, W. (2000). Psychosocial correlates of prepartum and postpartum depressed mood. Journal of Affective Disorders, 59 (10), 31- 40.

2-   Dareshouri Mohammadi, Z., Bosaknejad, S., & Sarvghad, S. (2012).A survey on the effectiveness of stress management training with cognitive-behavioral group therapy approach on state/trait anxiety, pregnancy anxiety and mental health of primiparous women. Jentashapir, 3(4), 495-504.

3-   Figueiredo, B., & Conde, A. (2011).Anxiety and depression symptoms in women and men from early pregnancy to 3months postpartum: parity differences and effects. Journal of Affective Disorders, 132 (1-2), 146-157.

4-   Abdollahzadeh Rafi, M., Hassanzadeh Avval, M., Ahmadi, S. H., Taheri, M., & Hosseini, M. A. (2012). Relationship between social support with depression and anxiety during third trimester pregnancy. Iranian Journal of Nursing Research, 7 (26), 1-10 [Persian].

5-   Ibanez G, Charles MA, Forhan A, Magnin G, Thiebaugeorges O, Kaminski M, et al. Depression and anxiety in women during pregnancy and neonatal outcome: data from the EDEN mother-child cohort. Early Hum Dev 2012; 88(8): 643-9.

6-   Robbins E. Depression during pregnant. Birmingham psychology journal 2003; 63 (1):1-3.

7-   Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 2007; 110(5): 1102-12.

8-      Mangoli M, Ramezani T, Mohammad Alizadeh S. Screening mental disorders in pregnancy. Iran J Psychiatry Clin Psychol 2003; 8(4): 45-55. [In Persian].

9-     Shayeghian Z., RasolzadehTabatabaey SK., Seddighilooye E. Effect of Maternal Anxiety during Third Trimester of Pregnancy Outcomes and Infants' Mental Health. Hayat, 2008, 14(3). 57-64.

10- Isohanni M, Jones P, Kemppainen L, Croudace T, Isohanni I, Veijola J, et al. Childhood and adolescent predictors of schizophrenia in the Northern Finland 1966 birth cohort--a descriptive life-span model. Eur Arch Psychiatry Clin Neurosci 2000; 250(6): 311-9.

11- O'Keane V. Evolving model of depression as an expression of multiple interacting risk factors. Br J Psychiatry 2000; 177: 482-3.

12- Kinney DK, Munir KM, Crowley DJ, Miller AM. Prenatal stress and risk for autism. Neurosci Biobehav Rev 2008; 32(8): 1519-32.

13- Van den Bergh BR. Mulder EJ. Mennes M. Glover V. (2005). Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review. NeurosciBiobehav Rev, 29 (2), 237-258.

14- Cookson H., Granell, R., Joinson, C., Ben-Sholomo, Y., Henderson, J. Mother's anxiety during pregnancy is associated with asthma in their children. Journal of Allergy and Clinical Immunology 2009; 123 (4): 847-53.

15- O'Connor TG, Heron J, Golding J, Beveridge M, Glover V. Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry 2002; 180: 502-8.

16- Bhagwanani SG, Seagraves K, Dierker LJ, Lax M. Relationship between prenatal anxiety and perinatal outcome in nulliparous women: a prospective study. J Natl Med Assoc 1997; 89(2): 93-8.

17- Solchany JA. Promoting maternal mental health during pregnancy: Theory, practice and intervention. Washington, DC: NCAST Publications; 2001.

18- O'Connor TG, Caprariello P, Blackmore ER, Gregory AM, Glover V, Fleming P. Prenatal mood disturbance predicts sleep problems in infancy and toddlerhood. Early Hum Dev 2007; 83(7): 451-8.

19- O'Connor TG, Ben-Shlomo Y, Heron J, Golding J, Adams D, Glover V. Prenatal anxiety predicts individual differences in cortisol in pre-adolescent children. Biol Psychiatry 2005; 58(3): 211-7.

20- McFarland J, Salisbury AL, Battle CL, Hawes K, Halloran K, Lester BM. Major depressive disorder during pregnancy and emotional attachment to the fetus. Arch Womens Ment Health 2011; 14(5): 425-34.

21- Bunevicius, A., & Cesnaite, E. (2007). Antenatal maternal mental state and anthropometric characteristics of the neonates: impact of symptoms of depression and anxiety. Biologin e Psichiatrja, 91, 3-6.

22- World Health Organization Report. Maternal mental health and child health and development in low and middle income countries: report of meeting held in Geneva, Switzerland.  Available from Accessed October 12, 2013.

23- Zuckerman B, Bauchner H, Parker S, Cabral H. Maternal depressive symptoms during pregnancy, and newborn irritability. J Dev Behav Pediatr 1990; 11(4): 190-4.

24- Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000; 95(4): 487-90.

25-  Pazande F, Toomians J, Afshar F, Valaei N. Prevalence of depression in parturients referring university hospitals in Tehran in 1999. Feyz 2002; 6(1): 66-70. [In Persian].

26-  Karbakhsh M, Sedaghat M. Depression during pregnancy: Pregnant women need to integrate patient care. Payesh Health Monit 2002; 1(4): 49-55. [In Persian].

27-  Shahhosseini Z, Abedian K, Azimi H. Role of anxiety during pregnancy in preterm delivery. J Zanjan Univ Med Sci 2008; 16(63): 85-92. [In Persian].

28-  Bjelica A, Kapor-Stanulovic N. Pregnancy as a psychological event. Med Pregl 2004; 57(3-4): 144-8. [In Serbian].

29- Littleton, L. Y., & Engebretson, J. C. (2002). Physiologic and behavioral transition to extra uterine life. In L.y Littleton, J. C Engebretson. (Ed.), Maternal, neonatal and women’s health nursing. Australia: Delmar Adinision of Thomson Learning.

30- Cunningham F. Gary. (1390). Williams Obstetrics. (Razaghy Z, Trans). Tehran: Arjomand. (Original work published 2010) [Persian].

31- Kliegman, R. M. and et al. (1390). Nelson Textbook of pediatrics.(Khosravi N, Mohamadpoor F, Jafari SH, Trans). ArtinpublishersMedicine. (Original work published 2011) [Persian].

32- Odd, D. E., Rasmussen, F., Gunnell, D., Lewis, G., & Whitelaw, A. (2008). A cohort study of low Apgar scores and cognitive outcomes. Archives of Disease in Childhood Fetal and Neonatal, 93(2), 115-120. 

33- Forouzandeh N. Delaram M. Deris F. (2002). The quality of mental health status in pregnancy and its contributing factors on women visiting the health care centers of Shahrekord. Journal of Reproduction and Infertility, 2(4), 147-155.

34-  Tabrizi M, Lorestani Kh. Effectiveness of the eclectic counseling in decreasing depression during pregnancy and preventing postnatal depression. Andisheh va Raftar 2010; 5(17): 19-26. [In Persian].

35-  Guido G., Ricardo F. M. Impact  of  a  prenatal  cognitive-behavioral  stressmanagement  intervention  on  salivary  cortisol  levelsin  low-income  mothers  and  their  infants. Psychoneuroendocrinology 2011; 36: 1-15.

36-  Fatehizadeh M., Banazadeh Z .M. S., Baghban I. A study on effectiveness of behavioral couple therapy on depression during pregnancy. Journal of Family Research 2007; 3(9): 421-430. [Persian].

37-  Austin MP., Frilingos M., Lumley J., HadziPavlovic D., Roncolato W., Acland S., et al. Brief antenatal cognitive behavior therapy group intervention fortheprevention of postnatal depression and anxiety:Arandomised controlled trial.Journal of Affective Disorders 2008; 105(1-3): 35–44.

38-  Hosseininasab D., Taghavi S., Ahmadiyan S. The Effectiveness of Prenatal Education in Decreasing the Childbirth Pain and Anxiety. Medical Science & Health Service 2010; 31(4): 24-30. [Persian].

39-  MosaviaslSA.,Kharamin SHA., Hadinia A., Rakhsha SHR., PoursamadA.The Role of Relaxation Training to Pregnant Mothers on Health Index of Infants.Armaghane-danesh 2009, 14(2), 97-104.

40-  Yang, M., Li, L., Zhu, H., Alexander, I., Liu, Sh., Zhou, W., & et al. Music therapy to relieve anxiety in pregnantwomen on bedrest: a randomized, controlled trial. J Matern Child Nurs 2009, 34, 316-323.

41-  Joanna, J., Arch S. D.Are exposure-based cognitive behavioral therapies safeduring pregnancy? Arch women’s Mental Health 2012, 15 (6): 445-475.

42-  Spielberger C. D., Richard L. (1970). STAIManual for the State-trait AnxietyInventory. Palo Alto, C. A: Consulting Psychologists Press.

43-  Taylor J. A.(1953). A personality scale of manifest anxiety.Journal of behavioral and social psychology, 48: 285-290.

44-  Dunkel-schetter C. (1998). Maternal stress and preterm delivery. Prenatal and Neonatal Medicine, 3: 39-42.

45-  Dipietro J. A., Ghera M. M., Costigan K., Hawkins M. (2004). Measuring the ups & downs pregnancy stress. Journal of Psychosomatic Obstetrics and Gynecology, 25: 189-201.

46-  Antoni Michael H., Ironson G., Schneiderman N. (1388). Cognitive- Behavioral stress management. (All Mohammad J. joker S. neshatdoost, Trans). AcademicJihadIsfahan. (Original work published 2007): 33-230 [Persian].

47-  Delavar A. Theoric and Scientificresearch in humanistic science.Tehran:Roshd publisher, 1995 [Persian].

48-  Vandenberg B. The influence of maternal emotional during pregnancy on fetal & neonatal behavior. Pre-and Prenatal Psychology Journal 1990; 5(2): 119-130.

49-  Babanazari L., Kafi S.M. Anxiety to its Different Periods, Sexual Satisfaction and Demographic Factors. Iraninan Psychiatry and Clinical Psychology 2008; 14(2): 206-213. [Persian].

50-  Huizink A.C., Robles de Medina P., Muder E. J. H.,Visser G., Buistelaar J. (2000). Is pregnancy anxiety a relatively distinctive syndrome? Retrieving from http://www.Early Human Development.

51-  Cox J. L., Holden J. M., Sagovsky R. Detection of postnatal depression: Development of the 10 item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 1987; 150: 782-6.

52-  Leahy Robert L. (1389). Cognitive therapy techniques: a practitioner’s guide.  (Hamid poor H. Andooz Z, Trans). (Original work published 2003).386-405[Persian].