Study design and procedures

We carried out a cross-sectional investigation at two teaching hospitals affiliated with Babol University of Medical Sciences in addition to a private obstetric clinic, from September 2018 to April 2019. The inclusion criteria were pregnant women aged above 18 years and with a minimum of five years of education. Women with a high-risk pregnancy, including hypertension, diabetes, maternal bleeding, and preterm labor, on top of those with a history of serious medical conditions, psychiatric problems, and drug abuse /alcohol addiction were excluded.

In order to recruit the subjects, we used convenience sampling method. Prior to starting the research, we calculated the ratio of pregnancy stress in a pilot study (P =0.6). The sample size was thus assessed as 188 with respect to α=0.05, P=0.6, and d=0.07. The researchers increased the number to 200 to compensate for the incomplete and missing data (n=frac{{left({Z}_{1-frac{alpha }{2}}right)}^2pleft(1-pright)}{(d)^2}).

Two important influential factors that should be considered include socio-economic status and living in cities or villages. In order to control these factors, the sampling location of the pregnant women was taken into consideration so that the effect of these factors on the results could be controlled. Thus, the sampling was performed from two secondary and tertiary perinatal hospital centers (Yahyanejad and Ayatollah Rohani) so that the rural and low-income women could also be sampled. Furthermore, a private practice was randomly selected to include women with a high level of socio-economic status in the sampling. Thus, 100 rural women were selected equally from both hospitals (50 patients per hospital) in addition to 100 urban women from private offices, to control both socio-economic status and place of residence.

A total of 245 pregnant women were asked to participate in the study via convenient sampling. They were recruited by a member of the research team (first author) and two midwives, who interviewed the women and gathered their medical and obstetric histories, as well as demographic information, in order to determine their obstetric risks and appropriateness based on the inclusion criteria. Furthermore, the midwives gave the ladies a brief explanation about the study’s objective and how to fill out the surveys. The midwives entered every eligible women in the study. Eventually, 200 eligible women (100 women living in village and 100 in city) provided written informed consent. Accordingly, the response rate was 81.6%.

All the 200 participants completed two self-reported questionnaires in their prenatal care appointments. These questionnaires included the Social Support Questionnaire (SSQ) and Revised Prenatal Distress Questionnaire (NuPDQ) (15-17).

The Medical Ethics Committee of Babol University of Medical Sciences approved this study (IR.MUBABOL.HRI.REC.1397.108).

Measurement

Social Support Questionnaire (SSQ)

Fleming et al. (1982) developed this questionnaire which comprises 25 items with five subscales (social support from families, neighbors, friends, and general, and view about these supports). The responders would reply to each item as yes/no. The range of the total score was between 0 and 25 [15]. The validated Persian version of SSQ [16] was used in this research. Herein, the Cronbach’s alpha for the subscales’ internal consistency ranged from 0.86 to 0.95.

Revised Prenatal Distress Questionnaire (NuPDQ)

This questionnaire is a modified version of the PDQ, with both tools being frequently employed for assessing pregnancy stress [17, 18]. NuPDQ consists of 17 items evaluating certain pregnancy-related worries, such as bodily changes, fetal health, physical symptoms, and delivery. The pregnant women rate their level of “worry” on a scale varying from 0 (not at all) to 2 (very much). The total score ranges from 0 to 32. In the current work, Cronbach’s alpha for internal consistency of the scale was 0.91. We used the NuPDQ’s validated Persian version with five aspects, namely medical problem, parenting, infant healthy, pregnancy symptom, and fear of childbirth [19].

Statistical analysis

The descriptive analysis of all the variables (age, parity, gestational age, pregnancy specific-stress, and social support) was presented as percentages, means, and standard deviation. Since the quantitative variables of the study, such as self-care, depression, and fear of COVID-19, followed a normal distribution, we used parametric tests to compare the means. The mean comparison of pregnancy stress and social support between the village residents and city residents was performed utilizing student t tests. The correlations between social support and pregnancy-associated stress were measured with Pearson’s test. In order to explore the associations between the five subscales of pregnancy stress, social support was embedded into two linear regression analyses with adjusted and non-adjusted models. Based on each subscale of social support (social support from the side of families, neighbors, friends, as well as the public, along with view about such supports), a number of simple linear regression models were developed. Five variables, including age, place of living, level of education, job, gestational age, and duration of marriage, were considered as covariates in the adjusted models. The Statistical Package for the Social Sciences (SPSS) software (version 18.0 ) was used to analyze the data. A significant level was defined as a P-value of <0.05.

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