Exploring Self-Perceived Stress and Anxiety Throughout Pregnancy: A Longitudinal Study

Abstract

Background: Anxiety and stress are common during pregnancy and can impact the health of the pregnant woman and the newborn. There is a lack of research focused on identifying weaknesses that promote equity in the care of pregnant women. The objective of this study was to describe the levels of anxiety and stress during the three trimesters of pregnancy and to compare whether there are differences according to obstetric and gynecological variables. Methods: A descriptive prospective longitudinal and correlational observational study was carried out. Non-probability sampling was carried out with 176 women. The Pregnancy-Related Anxiety Questionnaire and the Perceived Stress Scale were used. Results: The prevalence of anxiety was 23.9%, 17%, and 17.6%, and mean stress scores reached 32.24, 33.02, and 49.74 in the first, second, and third trimesters, respectively. In comparison, without miscarriages, anxiety was higher during the first trimester. In multiparous women who had suffered a miscarriage, anxiety was higher in the first trimester. Conclusions: Anxiety is higher during the first trimester. Mean stress levels are higher during the third trimester compared to the other two trimesters. Care for these vulnerable pregnant women can impact society’s health system and align with the Sustainable Development Goals of Health and Well-being and Gender Equality in others.

Full text

Academic Editor: Domenico De
Berardis
Received: 12 February 2025
Revised: 6 April 2025
Accepted: 16 April 2025
Published: 19 April 2025
Citation: Redondo, M.M.;
Liebana-Presa, C.; Pérez-Rivera, J.;
Martín-Vázquez, C.; Calvo-Ayuso, N.;
García-Fernández, R. Exploring
Self-Perceived Stress and Anxiety
Throughout Pregnancy: A
Longitudinal Study. Diseases 2025,13,
121. https://doi.org/10.3390/
diseases13040121
Copyright: © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/
licenses/by/4.0/).
Article
Exploring Self-Perceived Stress and Anxiety Throughout
Pregnancy: A Longitudinal Study
Mar Miguel Redondo 1, Cristina Liebana-Presa 2, * , Javier Pérez-Rivera 3, * , Cristian Martín-Vázquez 4,
Natalia Calvo-Ayuso 5and Rubén García-Fernández 5,6
1Centro de Salud Roces Montevil, Gijón, Servicio de Salud del Principado de Asturias, 33001 Asturias, Spain;
guel@sespa.es
2HeQoL Research Group, Faculty of Health Sciences, Universidad de León, Campus Universitario de
Vegazana, 24071 León, Spain
3SALBIS Research Group, Faculty of Health Sciences, Universidad de León, Campus Universitario de
Vegazana, 24071 León, Spain
4HeQoL Research Group, Faculty of Health Sciences, Universidad de León, Campus Universitario de
Ponferrada, 24401 Ponferrda, Spain; cmartv@unileon.es
5SALBIS Research Group, Faculty of Health Sciences, Universidad de León, Campus Universitario de
Ponferrada, 24401 Ponferrda, Spain; ncala@unileon.es (N.C.-A.); rgarcf@unileon.es (R.G.-F.)
6Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon,
1600-096 Lisbon, Portugal
*Correspondence: cliep@unileon.es (C.L.-P.); fjperr@unileon.es (J.P.-R.)
Abstract: Background: Anxiety and stress are common during pregnancy and can impact
the health of the pregnant woman and the newborn. There is a lack of research focused on
identifying weaknesses that promote equity in the care of pregnant women. The objective
of this study was to describe the levels of anxiety and stress during the three trimesters
of pregnancy and to compare whether there are differences according to obstetric and
gynecological variables. Methods: A descriptive prospective longitudinal and correlational
observational study was carried out. Non-probability sampling was carried out with
176 women
. The Pregnancy-Related Anxiety Questionnaire and the Perceived Stress Scale
were used. Results: The prevalence of anxiety was 23.9%, 17%, and 17.6%, and mean
stress scores reached 32.24, 33.02, and 49.74 in the first, second, and third trimesters,
respectively. In comparison, without miscarriages, anxiety was higher during the first
trimester. In multiparous women who had suffered a miscarriage, anxiety was higher in
the first trimester. Conclusions: Anxiety is higher during the first trimester. Mean stress
levels are higher during the third trimester compared to the other two trimesters. Care for
these vulnerable pregnant women can impact society’s health system and align with the
Sustainable Development Goals of Health and Well-being and Gender Equality in others.
Keywords: anxiety; health; longitudinal studies; pregnancy; stress
1. Introduction
The social, psychological, and hormonal changes inherent to pregnancy frequently
precipitate mood disturbances in expectant mothers with a notably high prevalence [
1
,
2
].
Stress and anxiety are among the most common mental health challenges during this period
and are often closely interlinked [2,3].
Concerns about pregnancy and childbirth causing pregnancy-specific anxiety or af-
fecting fetal development are widespread, affecting up to one in five women [
4
]. However,
global prevalence rates significantly vary and are influenced by cultural factors [
5
,
6
] or
nulliparity [
7
]. Anxiety has profound implications for the hypothalamic–pituitary–adrenal
Diseases 2025,13, 121 https://doi.org/10.3390/diseases13040121

Diseases 2025,13, 121 2 of 13
axis, inducing systemic inflammation and increasing the risk of obstetric complications [
8
],
including recurrent miscarriage [
8
], hypertensive disorders, and impaired fetal growth [
7
].
Furthermore, maternal anxiety is associated with cognitive, linguistic, and socio-emotional
developmental difficulties in offspring [9,10].
In countries like Japan and the Netherlands, the prevalence of anxiety during preg-
nancy is relatively low. This can be attributed to strong social support systems, universal
access to prenatal care, and specific educational programs for pregnant women. In contrast,
in countries with fewer resources, the lack of social support and limited access to medical
care can increase the prevalence of anxiety [5].
Similarly, stress is recognized as a prevalent health concern, particularly early in preg-
nancy [
2
]. Its adverse effects extend to pregnancy and labor outcomes [
11
,
12
], significantly
affecting child development. Elevated maternal stress increases cortisol levels, increas-
ing fetal cortisol levels and potentially inducing epigenetic modifications [
11
,
12
]. Such
alterations heighten the risk of physical conditions such as asthma [
13
] or congenital heart
disease [14] and emotional and affective disorders [15,16].
Women who are pregnant for the first time (nulliparous) tend to experience higher
levels of anxiety due to the lack of previous experience and fear of the unknown. In coun-
tries with well-established prenatal education programs, these concerns can be mitigated
through information and support [8].
Complications such as pre-eclampsia or gestational diabetes can significantly increase
levels of anxiety and stress. In countries with robust healthcare systems, early detection
and proper management of these complications can act as protective factors [7].
There is a relatively large literature on stress, anxiety, and depressive symptoms
during pregnancy and their implication for postpartum depression [
17
], newborn body
composition [
18
], inflammatory response about social variables [
19
], delayed development
of motor and communication skills during infancy [
20
], infant mental health [
21
], and the
impact of the effects of stress and anxiety on the development of infant mental health [
21
].
Despite the prevalence of pregnancy-related psychopathology, existing research is
inconsistent [
4
]. While some studies indicate heightened stress prevalence early in preg-
nancy [
22
], often accompanied by increased anxiety [
23
–
26
], there are progressive increases
in these conditions across trimesters [
27
]. The limited availability of longitudinal stud-
ies [
6
] underscores the need for research that elucidates these dynamics, enabling tailored
interventions [
28
]. Such efforts could promote a balanced maternal neuroendocrine system,
improving obstetric and neonatal outcomes [
9
,
29
]. Understanding the health status in this
group of women allows for the identification of factors that may affect their physical and
psychological well-being, the implications this may have on the health of the newborn [
30
],
as well as the promotion of well-being and gender equity in the care of pregnant women.
The COVID-19 pandemic has significantly impacted the mental health of pregnant
and postpartum women. A study conducted in Italy during the three years of the pan-
demic revealed that women who gave birth without their partner’s presence experienced
higher levels of depression and post-traumatic stress, as well as lower psychological well-
being [
31
]. Additionally, the psychological burden related to the pandemic and individual
coping strategies influenced the risk of developing postpartum depressive symptoms [
32
].
The lack of support and forced quarantine increased feelings of fatigue and isolation,
exacerbating anxiety and depression symptoms in pregnant and postpartum women [33].
This study aims to explore and analyze prenatal anxiety and stress according to
obstetric and gynecological factors in the different trimesters of pregnancy.

Diseases 2025,13, 121 3 of 13
2. Materials and Methods
A longitudinal prospective correlational study was conducted using non-probabilistic
convenience sampling. Initially, 466 pregnant women from a health area in the north of
Spain were contacted in the first trimester. A total of 360 pregnant women responded to
the questionnaires, comprising 77.25% of the total women who were contacted. As this
was a longitudinal study, participation was lost in the second and third trimesters, and the
final participation comprised 176 pregnant women. The inclusion criteria were (i) to be
before the 10th week of gestation; (ii) to be of legal age; (iii) to have a low-risk pregnancy;
and (iv) to give informed consent to participate in the study. Exclusion criteria included
(i) the presence of medical or psychological disorders limiting their ability to understand
this research and the questions in the questionnaires; (ii) when the pregnancy is considered
high risk by the Spanish Society of Gynecology; and (iii) being under 18 (legal age in
Spain). Participants ranged in age from 20 to 44 years, with a mean of 34.19
±
4.49 years.
Socio-demographic and obstetric–gynecologic characteristics are described in Table 1.
Table 1. Socio-demographic and obstetric–gynecologic characteristics of participants.
Variables n 176 (100%)
Marital status Married/inhabiting 140 (79.5%)
single/widowed 36 (20.5%)
Educational level
University education 72 (40.9%)
Postgraduate 24 (13.6%)
Primary education 4 (2.3%)
Secondary education 76 (43.2%)
Nationality Spanish 170 (96.6%)
Other 6 (3.4%)
Area of residence Rural 60 (34.1%)
Urban 116 (65.9%)
Parity One 93 (52.8%)
Two or more 83 (47.2%)
Abortions
Zero 124 (70.5%)
One 41 (23.3%)
Two or more 11 (6.3%)
Vaginal births
Zero 127 (72.2%)
One 45 (25.6%)
Two or more 4 (2.3%)
Cesarean sections
Zero 148 (84.1)
One 26 (14.8%)
Two or more 2 (1.1%)
Conception Spontaneous 166 (94.3%)
Assisted reproduction 10 (5.7%)
In 2022, 484 births were registered in the region analyzed (Junta de Castilla y León,
Spain, 2022) [
34
]. For this study, the minimum necessary sample size was calculated using
a formula based on the population proportion [
35
], assuming a confidence level of 95%
and a margin of error (d) of 3%. As a result, it was determined that 143 participants were
needed for the sample.

Diseases 2025,13, 121 4 of 13
2.1. Instruments
The data collection instruments included a personal information form created by the
researchers with obstetric–gynecologic and socio-demographic variables and the validated
pregnancy-related anxiety and stress questionnaires.
The Pregnancy-Related Anxiety Questionnaire (PRAQ-20) [
24
], validated in Spanish,
consists of 20 items grouped into five factors: (i) concerns about changes in oneself; (ii) fear
for the baby’s integrity; (iii) feelings about oneself; (iv) fear of childbirth; and (v) concerns
about the future. Each item is scored on a Likert-type scale. With five response options
ranging from 1 (strongly disagree) to 5 (strongly agree), the total score ranges from 20 to 100.
The cut-off point of the scale is 67 (85th percentile); women scoring at or above this level
will show a high level of gestational anxiety. This tool is considered helpful for measuring
anxiety in pregnancy in both multiparous and nulliparous women. The reliability of this
PRAQ-20 scale in Spanish [
24
] was 0.91 during the first and third trimesters and 0.93 during
the second and third.
The Perceived Stress Scale (PSS) [
36
] is a scale validated in Spanish that measures the
degree to which everyday situations are stressful, considering feelings and thoughts during
the previous month. The Spanish version consists of 14 items, each scored on a Likert-type
scale of 0 to 4 (0 = never, 4 = always). The minimum score is 0, and the maximum score is
56. This scale demonstrated reliability, validity, and sensitivity with a Cronbach’s alpha of
0.81 in its validation for the Spanish population [36].
2.2. Procedure
The pregnant women participating in this study were recruited in the first trimester
of gestation. After the first routine obstetric control visit at the reference hospital of
the Health Care Management of a region located in the north of Spain, the researchers
individually informed the pregnant women about the present study in a consultation
lasting no more than 5 min. If the pregnant woman agreed to participate, after read-
ing and signing the informed consent form, she was asked for her e-mail address or
telephone number to be contacted by e-mail or Whatsapp
®
, respectively, and to send
the corresponding forms prepared for this study using Google Forms
®
. In total, the
pregnant women were approached on three different occasions: the first before 10 weeks
of gestation (first trimester), the second after 12 weeks (second trimester), and the third
after 36 weeks (third trimester). The average response time for the initial questionnaire
was 15 min, while the average response time for the subsequent questionnaires was
10 min.
Participants did not receive any compensation for participation in this study.
Data were collected between September 2021 and March 2023.
2.3. Data Analysis
All data obtained were processed and analyzed using SPSS Statistics V28.0 (IMB.
Armonk, NY, USA). In the descriptive analysis of the variables, the frequency of central
tendency and dispersion measures were used. The repeated models ANOVA statistical
test with Bonferroni correction was performed to compare the means of the presence of
stress (PSS) and anxiety (PRAQ-20). This statistical test was also used to compare these
variables under study according to different obstetric–gynecologic variables (parity, type
of conception, and number of miscarriages). The partial eta squared test was used to
measure the effect size. p-values of less than 0.05 were considered significant. Cronbach’s
coefficient was also used for the psychometric analysis of the reliability of the PSS and
PRAQ-20 scales.

Diseases 2025,13, 121 5 of 13
2.4. Ethical Considerations
This study was reviewed and approved by the Institutional Ethics Committee of a
Spanish public university (ETICA-ULE-033-2021) and had a favorable report from the
Research Ethics Committee of the Health Areas of the northern region of Spain (internal
registry 21124), where the pregnant women were attended. This study complies with
the international research recommendations proposed by the Declaration of Helsinki, the
Belmont Report, and the Oviedo Convention. Organic Law 3/2018 of 5 December on
Personal Data Protection and Guarantee of Digital Rights was applied. Participants gave
their individual written informed consent to participate in this study.
3. Results
The prevalence of anxiety was 23.9% in the first trimester, 17% in the second trimester,
and 17.6% in the third trimester of gestation. In addition, the mean values of anxiety and
stress in the different trimesters of gestation are shown in Figure 1.
Table 2shows the psychometric analyses of the reliability of the questionnaires used,
PSS and PRAQ-20, and the dimensions of the latter questionnaire.
Table 2. Psychometric analysis of the reliability of the PRAQ-20 and PSS.
Variable α
Perceived Stress Scale (PSS)
1st T 0.882
2nd T 0.954
3rd T 0.923
Pregnancy-Related Anxiety Questionnaire-20 (PRAQ-20)
1st T 0.909
2nd T 0.912
3rd T 0.916
Concern for change in oneself
1st T 0.774
2nd T 0.896
3rd T 0.872
Fear for the integrity of the baby
1st T 0.917
2nd T 0.910
3rd T 0.919
Feelings about oneself
1st T 0.849
2nd T 0.834
3rd T 0.808
Fear of childbirth
1st T 0.822
2nd T 0.850
3rd T 0.852
Concern about the future
1st T 0.732
2nd T 0.645
3rd T 0.715
α: Cronbach’s alpha.
In Table 3, descriptive statistics and mean differences of anxiety and stress variables
are detailed according to the gestational trimester. Stress scores were statistically higher
in the third trimester compared to the first and second trimesters. However, regarding
total anxiety, women in the first trimester of pregnancy had higher values than those in the
third and second trimesters. Specifically, concerning the dimensions of the PRAQ-20, it is
noteworthy that concern about changes in oneself and fear for the baby’s integrity were
statistically higher in the first trimester than in the other two trimesters.

Diseases 2025,13, 121 6 of 13
Diseases2025,13,xFORPEERREVIEW6of15


2.4.EthicalConsiderations
ThisstudywasreviewedandapprovedbytheInstitutionalEthicsCommieeofa
Spanishpublicuniversity(ETICA-ULE-033-2021)andhadafavorablereportfromthe
ResearchEthicsCommieeoftheHealthAreasofthenorthernregionofSpain(internal
registry21124),wherethepregnantwomenwereaended.Thisstudycomplieswiththe
internationalresearchrecommendationsproposedbytheDeclarationofHelsinki,the
BelmontReport,andtheOviedoConvention.OrganicLaw3/2018of5Decemberon
PersonalDataProtectionandGuaranteeofDigitalRightswasapplied.Participantsgave
theirindividualwrieninformedconsenttoparticipateinthisstudy.
3.Results
Theprevalenceofanxietywas23.9%inthefirsttrimester,17%inthesecond
trimester,and17.6%inthethirdtrimesterofgestation.Inaddition,themeanvaluesof
anxietyandstressinthedifferenttrimestersofgestationareshowninFigure1.

Figure1.DescriptivestatisticsofPRAQ-20andPSSbytrimesters*p>0.05.
Table2showsthepsychometricanalysesofthereliabilityofthequestionnairesused,
PSSandPRAQ-20,andthedimensionsofthelaerquestionnaire.
Table2.PsychometricanalysisofthereliabilityofthePRAQ-20andPSS.
Variable𝛼
PerceivedStressScale(PSS)
1stT0.882
2ndT0.954
3rdT0.923
Pregnancy-RelatedAnxietyQuestionnaire-20(PRAQ-20)
1stT0.909
2ndT0.912
3rdT0.916
Concernforchangeinoneself
1stT0.774
2ndT0.896
3rdT0.872
Fearfortheintegrityofthebaby
1stT0.917
2ndT0.910
3rdT0.919
Feelingsaboutoneself
1stT0.849
2ndT0.834
3rdT0.808
Fearofchildbirth
1stT0.822
2ndT0.850
3rdT0.852
Figure 1. Descriptive statistics of PRAQ-20 and PSS by trimesters * p> 0.05.
Table 3. Descriptive statistics and mean differences by trimester for PRAQ-20 and PSS.
Variable 1st T
M(SD)
2nd T
M(SD)
3rd T
M(SD) C M.diff SD pη2
p
Perceived Stress Scale (PSS) 32.24
(5.46)
33.02
(4.61)
49.74
(6.48)
1-2 −0.78 0.49 0.334
0.993
1-3 −17.50 * 0.65 <0.001
3-2 16.72 * 0.60 <0.001
Pregnancy-Related Anxiety
Questionnaire-20 (PRAQ-20)
57.18
(15.51)
52.16
(15.49)
52.09
(15.88)
1-2 5.01 * 0.82 <0.001
0.935
1-3 5.08 * 0.95 <0.001
2-3 0.07 0.78 1
Concern for change in oneself 7.26
(3.32)
6.45
(3.39)
6.25
(3.26)
1-2 0.80 * 0.21 <0.001
0.839
1-3 1.01 * 0.22 <0.001
2-3 0.20 0.19 0.833
Fear for the integrity of the baby 27.9
(7.31)
24.6
(7.66)
24.57
(7.89)
1-2 3.29 * 0.43 <0.001
0.934
1-3 3.33 * 0.48 <0.001
2-3 0.04 0.38 1
Feelings about oneself 6.75
(3.32)
6.51
(3.00)
6.32
(3.02)
1-2 0.24 0.18 0.553
0.850
1-3 0.43 0.21 0.128
2-3 0.18 0.19 1
Fear of childbirth 10.60
(4.68)
9.99
(4.70)
10.33
(4.82)
1-2 0.62 0.28 0.088
0.861
1-3 0.28 0.31 1
2-3 −0.34 0.29 0.736
Concern about the future 4.66
(2.35)
4.60
(2.11)
4.63
(2.12)
1-2 0.06 0.15 1
0.860
1-3 0.04 0.16 1
2-3 −0.02 0.14 1
Abbreviations: 1st T: first trimester; 2nd T: second trimester; 3rd T: third trimester; M(SD): mean (standard
deviation); C: trimesterly comparison; M.diff: mean difference; *: p< 0.05; η2
p: partial eta squared.
The results showed statistically significant differences between women who had one
or more previous abortions and those who had no previous abortions. Third-trimester
women with previous abortions (57.05
±
15.18) had a higher level of anxiety than those
who did not have previous abortions (50.01 ±15.76), (t (174) = −2.73; p= 0.003).
Table 4describes the results achieved for stress and anxiety levels according to parity
and trimester of gestation. Thus, in primiparous women, the anxiety score is statistically
higher in the first trimester than in the third and second trimesters. Worries about changes in
oneself, fear for the baby’s integrity, and fear of childbirth follow the same trend. Regarding
stress, first-time pregnant women showed higher values in the third trimester than in the
first and second trimesters. On the other hand, in multiparous pregnant women, anxiety
was higher in the first trimester than in the second; in particular, the dimensions of fear of

Diseases 2025,13, 121 7 of 13
childbirth also follow this trend. Stress is still higher in the third trimester than in the first
and second trimesters in women who have been previously pregnant.
Table 4. Descriptive statistics and mean differences by trimester and parity on PRAQ-20 and PSS.
Variable 1st T
M(SD)
2nd T
M(SD)
3rd T
M(SD) C M.diff SD pη2
p
Primiparous
Perceived Stress Scale (PSS) 31.71
(5.50)
32.84
(4.72)
50.53
(4.98)
1-2 −1.24 0.72 0.260
1-3 −18–82 * 0.80
<0.001
0.994
3-2 17.58 * 0.67
<0.001
Pregnancy-Related Anxiety
Questionnaire-20 (PRAQ-20)
57.34
(16.68)
51.68
(14.94)
50.77
(15.68)
1-2 5.67 * 1.16
<0.001
1-3 6.57 * 1.36
<0.001
0.934
3-2 −0.90 1.19
<0.001
Concern for changes in oneself 6.89
(3.05)
6.25
(2.86)
5.92
(2.90)
1-2 0.64 * 0.24 0.026
1-3 0.97 * 0.28 0.003 0.866
3-2 −0.32 0.29 0.807
Fear for the integrity of the baby
27.41
(7.88)
23.48
(8.00)
22.94
(8.29)
1-2 3.92 * 0.63
<0.001
1-3 4.47 * 0.72
<0.001
0.921
3-2 −0.55 0.56 0.994
Feelings about oneself 6.10
(3.05)
6.08
(2.49)
6.04
(2.74)
1-2 0.22 0.24 1
0.872
1-3 0.05 0.28 1
3-2 −0.03 0.27 1
Fear of childbirth 12.02
(4.69)
11.00
(4.66)
11.15
(4.78)
1-2 1.01 0.42 0.051
1-3 0.86 0.42 0.130 0.888
3-2 0.15 0.45 1
Concern about the future 4.94
(2.46)
4.87
(2.16)
4.72
(2.07)
1-2 0.06 0.23 1
0.873
1-3 0.21 0.23 1
3-2 −0.15 0.21 1
Multiparous
Perceived Stress Scale (PSS) 32.84
(5.39)
33.11
(4.51)
48.87
(7.76)
1-2 −0.26 0.65 1
1-3 −16.02 * 1.03
<0.001
0.991
3-2 15.76 * 1.02
<0.001
Pregnancy-Related Anxiety
Questionnaire-20 (PRAQ-20)
56.99
(14.19)
52.71
(16.16)
53.58
(16.07)
1-2 4.23 * 1.15 0.001
1-3 3.41 * 1.29 0.030 0.936
3-2 0.87 0.97 1
Concern for changes in oneself 7.66
(3.57)
6.69
(3.91)
6.61
(3.61)
1-2 0.98 * 0.35 0.021
1-3 1.05 * 0.35 0.011 0.819
3-2 −0.07 0.23 1
Fear for the integrity of the baby
28.45
(6.62)
25.87
(7.09)
26.40
(7.03)
1-2 2.58 * 0.58
<0.001
1-3 2.05 * 0.61 0.004 0.950
3-2 0.53 0.52 0.921
Feelings about oneself 7.48
(3.46)
6.99
(3.46)
6.64
(3.30)
1-2 0.49 0.28 0.237
1-3 0.84 * 0.31 0.022 0.842
3-2 −0.35 0.26 0.526
Fear of childbirth 9.04
(4.15)
8.86
(4.51)
9.41
(7.72)
1-2 0.18 0.37 1
0.844
1-3 −0.37 0.45 1
3-2 0.55 0.37 0.404
Concern about the future 4.36
(2.20)
4.31
(2.04)
4.52
(2.17)
1-2 0.05 0.76 1
0.847
1-3 −0.16 0.22 1
3-2 0.20 0.18 0.77
Abbreviations: 1st T: first trimester; 2nd T: second trimester; 3rd T: third trimester; M(SD): mean (standard
deviation); C: trimesterly comparison; M.diff: mean difference; *: p< 0.05; η2
p: partial eta squared.

Diseases 2025,13, 121 8 of 13
Regarding the results obtained for stress and anxiety levels according to the number of
miscarriages and trimester of gestation in women who had not experienced any miscarriage,
the anxiety score was statistically higher in the first trimester than in the third.
Concerning stress in women who have not experienced miscarriages, the score was
statistically higher during the third trimester than during the first and second trimesters.
On the other hand, in women who have experienced one miscarriage, anxiety has not
experienced a significant variation across trimesters. At the same time, stress remains
higher in the third trimester than in the second and first trimesters. In women who had
experienced two or more miscarriages, anxiety again showed no significant variation. At
the same time, stress followed the same trend, which was higher in the third trimester than
in the second and first trimesters.
The results were obtained for stress and anxiety levels according to the type of concep-
tion and trimester of gestation. In women with spontaneous pregnancies, the anxiety score
was statistically higher in the first trimester than in the second and third trimesters. For
stress, the score was statistically higher in the third trimester than in the first and second
trimesters. In women with assisted reproduction pregnancies, anxiety, and stress scores
did not significantly vary between trimesters.
4. Discussion
The results obtained show the self-perceived levels of anxiety and stress across the
three trimesters of pregnancy and help analyze the relationship between these variables.
They also compare differences in anxiety and stress based on obstetric–gynecologic vari-
ables and the trimester of pregnancy.
The PRAQ-20 scale shows high internal consistency, with values like those obtained
in the Spanish validation study [
24
] above 0.90 in all trimesters. It was found that the
prevalence of anxiety was statistically higher during the first trimester, being present in
23.9% of the participants. It was 17% and 17.6% during the second and third trimesters.
This decreasing evolution of the percentage of anxiety with a slight increase during the
third trimester, although not significant for this study, is like that previously obtained
by other authors [
24
,
26
]. When different versions of the PRAQ-20 with fewer items are
used, such as the PRAQ-20, mean anxiety values slightly lower than those in our study
are obtained [28,37].
As in previous studies, the different dimensions of PRAQ-20 show significant varia-
tions throughout trimesters [
28
]. In our study, fear for the baby’s integrity exhibited the
strongest positive correlations with the presence of anxiety in each trimester, followed by
fear of childbirth. These findings are consistent with previous research, which indicates that
such worries are closely linked to significant concerns during pregnancy. These concerns
include factors that may affect maternal and fetal health, potential complications during
childbirth, and social and economic support levels, among others [
38
]. Based on these
results, it may be interesting for future studies to evaluate the total anxiety score and
continue studying the different dimensions that influence its presence.
The PSS scale also demonstrates high internal consistency. with values exceeding
those reported in the Spanish validation study [
36
]. It reaches values above 0.90, except in
the first trimester, where it is 0.88. In our study, stress significantly increased during the
third trimester, with mean values of 32.24, 33.02, and 49.74 for the first, second, and third
trimesters, respectively. This progression aligns with recent longitudinal studies conducted
during the COVID-19 pandemic [
27
] but contrasts with pre-pandemic studies where stress
was highest during the first trimester and subsequently decreased [
22
]. Another aspect
to consider is that the mean stress levels reported in studies are generally lower than
in our research [
39
–
41
]. On the other hand, some studies identified stress levels in the

Diseases 2025,13, 121 9 of 13
first trimester during the pandemic similar to those observed in our study. Although the
samples in these studies differ, the target population remains the same [42].
The relationship between anxiety and stress in our study differs from what has been
previously proposed by other authors [
22
,
43
]. However, following the COVID-19 pandemic,
longitudinal studies have suggested that the evolution of both variables is similar to our
study findings [
27
]. Despite the differing trends in both variables, specific correlations were
consistent with those in prior research [
43
]. In our study, first-trimester stress positively
correlates with anxiety in the first and second trimesters. This aligns with other studies that,
despite identifying elevated stress and lower anxiety levels in the first trimester, observed
that the presence of anxiety symptoms increased the risk of stress and that stress acted as a
risk factor for the development of anxiety [
44
]. Additionally, in our study, the presence of
anxiety during pregnancy is associated with stress at the end of pregnancy. The dimension
of anxiety most strongly correlated with third-trimester stress involves self-related concerns
such as weight gain, which aligns with the increased correlation observed at the end of
pregnancy, a period when pregnant women reach their maximum weight [45].
Our study’s sample was homogeneous regarding gravidity: 52.8% were experienc-
ing their first pregnancy, while 47.2% had been pregnant before. Some studies suggest
multiparous women experience less stress during pregnancy [
46
,
47
]. However, in our
study, both groups exhibited statistically higher stress levels during the third trimester.
Regarding anxiety, previous studies indicate that primiparous women have higher lev-
els of anxiety [
2
,
47
,
48
]. In our study, anxiety was significantly higher during the first
trimester for both groups. However, in women who had been pregnant before [
49
], anxi-
ety slightly increased again during the third trimester. This may be related to concerns
about the baby’s well-being. as anxiety tends to slightly rise at the end of pregnancy
in women with previous pregnancies. This situation could stem from the approach to
childbirth, particularly in women with a personal history of obstetric complications in
earlier deliveries. It would be valuable to explore both parity and the nature of those past
experiences for future studies. As for the fear of childbirth, one of the most prevalent
dimensions of anxiety in our study, it remained stable among multiparous women; in
comparison, it was statistically higher for primiparous women during the first trimester.
It slightly increased again during the third trimester, likely due to the impending child-
birth for which they lack prior experience. Certain studies suggest that fear of childbirth
is generally greater in primiparous women [
38
], but a recent systematic review indicates
that both groups may experience similar levels of anxiety [49].
Regarding women with a history of miscarriages, most participants in our study
(70.5%) had not experienced any previous miscarriage, 23.3% had experienced one miscar-
riage, and 6.3% had experienced two or more. Previous studies indicate that stress and
anxiety are more frequent in women who have suffered recurrent miscarriages [
10
,
50
].
In our study, stress levels were statistically higher during the third trimester across all
groups. Anxiety levels, however, varied depending on the number of miscarriages. Women
with two or more miscarriages maintained elevated anxiety levels throughout the entire
pregnancy with no variability based on the trimester. In contrast, women with no prior
miscarriages experienced the highest levels of anxiety during the first trimester, followed
by a decline, possibly due to increased confidence in the pregnancy’s progress [
28
]. Women
who had experienced only one miscarriage showed a renewed increase in anxiety during
the third trimester.
In our study, the sample was heterogeneous in terms of conception method, with only
5.7% of the women having undergone assisted reproductive techniques. Previous studies
have associated this type of conception with reduced stress levels [
47
]. However, in our
study, both groups had higher stress levels during the third trimester.

Diseases 2025,13, 121 10 of 13
This study has several limitations. Firstly, the participants are low-risk pregnant
women, which may limit the generalizability of the results. Women with high-risk preg-
nancies may experience different patterns of stress and anxiety due to additional concerns.
Secondly, this study did not account for the presence of stressful life events unrelated to
pregnancy or other factors such as social support, employment status, associated psychi-
atric disorders, or pre-existing health conditions. However, this longitudinal salutogenic
approach aims to reaffirm the physiological nature of pregnancy, thereby providing a
foundation for future, more rigorous, and precise studies to document and address the
needs of various subgroups. It also highlights the importance of a preventive and health-
promoting approach for this population. Furthermore, recent studies should be designed
using longitudinal methodology, uncomplicating comparisons.
Although it is difficult to determine whether stress precedes anxiety or vice versa,
our findings suggest that early interventions aimed at reducing anxiety may have a
positive effect on the subsequent reduction in stress, thereby improving maternal and
neonatal outcomes.
This longitudinal study provides a comprehensive overview of the evolution of anxiety
and stress throughout the three trimesters of pregnancy. Understanding how these two
variables develop over time is crucial for designing more targeted and specific interventions,
protocols, and programs that address the holistic needs of pregnant women. Pregnancy
is a physiological process, so our proposed approach emphasizes health promotion and
disease prevention.
These interventions should be delivered primarily through primary healthcare, led
by nurses specialized in obstetrics and gynecology or by nurses specialized in family or
community health. This would enhance access to the healthcare system while reducing
unnecessary medicalization.
It is, therefore, recommended that more comprehensive prenatal education programs
be implemented, with a strong focus on the emotional and mental health needs of pregnant
women. Such programs could help reduce anxiety and stress, leading to improved maternal
and fetal health outcomes.
Furthermore, providing psychological and emotional support is essential. Pregnant
women should be equipped with tools to manage this period effectively, taking into
account the biopsychosocial factors influencing their well-being and promoting a healthier
pregnancy overall.
Implementing an early detection and management program for gestational complica-
tions is crucial. Early identification and management of complications can alleviate anxiety
and stress, thus improving obstetric outcomes.
Finally, developing and implementing social and economic support policies are crit-
ical to reducing stress related to financial concerns and access to healthcare, ultimately
contributing to the well-being of both mother and fetus.
5. Conclusions
Pregnancy-specific anxiety was higher in the participating pregnant women during the
first trimester compared to the other two trimesters. Specifically, 23.9% exhibited elevated
levels of this variable in the first trimester. Conversely, perceived stress among pregnant
women was higher in the third trimester as the moment of childbirth approached.
In primiparous women, those who have never experienced a miscarriage or those
with a spontaneous conception, anxiety remains higher in the first trimester. The most
concerning factors during this period include self-focused worries, fear for the baby’s
health, and fear of childbirth. The stress variable, however, continues to be higher in the
final trimester regardless of the parity, type of conception, or number of miscarriages.

Diseases 2025,13, 121 11 of 13
Effective interventions within prenatal health education programs that focus on re-
ducing anxiety at the beginning of pregnancy and managing emotional stress toward the
end could help alleviate concerns and improve pregnant women’s perception of their
health. Tailored interventions based on the type of parity or number of miscarriages could
positively impact the quality of care received. Furthermore, care for this vulnerable group
of pregnant women can affect the health system and society and align with the Sustainable
Development Goals of Health and Wellbeing and Gender Equality in others.
Based on the study results, we recommend implementing prenatal education programs
with stress- and anxiety-management techniques for the first trimester. Additionally,
emotional and psychological support sessions should be offered, especially for primiparous
women and those with a history of spontaneous abortions. These interventions can improve
pregnant women’s health perception and maternal and neonatal health outcomes.
Author Contributions: Conceptualization. C.L.-P. and R.G.-F.; methodology. M.M.R., C.L.-P. and
R.G.-F.; software. M.M.R., C.L.-P. and R.G.-F.; validation. M.M.R., C.L.-P. and R.G.-F.; formal analysis.
M.M.R., C.L.-P. and R.G.-F.; resources. C.L.-P. and R.G.-F.; data curation. R.G.-F.; writing—original
draft preparation. M.M.R., C.L.-P., J.P.-R., C.M.-V. and N.C.-A. writing—review and editing. C.L.-P.
and J.P.-R.; visualization. C.L.-P. and J.P.-R.; supervision. C.L.-P., J.P.-R., C.M.-V. and N.C.-A. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study complied with the Declaration of Helsinki and
was approved by the Institutional Ethics Committee of a Spanish public university (ETICA-ULE-033-
2021) with approval date 8 July 2021 and of the Clinical Research Ethics Committee of the Leon and
Bierzo Health Areas (approval number: 21124) of Spain for studies involving humans with approval
date 1 September 2021.
Informed Consent Statement: Informed consent was obtained from all subjects involved in
the study.
Data Availability Statement: The data analyzed in this study will be made available upon reasonable
request by the corresponding author.
Conflicts of Interest: The authors declare no conflicts of interest.
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