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Psychometric Evaluation of the Pregnancy-related Anxiety Scale:

Acceptance of Pregnancy, Avoidance, and Worry About Self
Subscales

Robyn Brunton , Katrina Gosper , Rachel Dryer

PII: S0165-0327(20)32759-2
DOI: https://doi.org/10.1016/j.jad.2020.09.064
Reference: JAD 12466

To appear in: Journal of Affective Disorders

Received date: 13 April 2019

Revised date: 14 May 2020
Accepted date: 11 September 2020

Please cite this article as: Robyn Brunton , Katrina Gosper , Rachel Dryer , Psychometric Evaluation
of the Pregnancy-related Anxiety Scale: Acceptance of Pregnancy, Avoidance, and Worry About Self
Subscales, Journal of Affective Disorders (2020), doi: https://doi.org/10.1016/j.jad.2020.09.064

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Psychometric Evaluation of the Pregnancy-related Anxiety Scale: Acceptance of

Pregnancy, Avoidance, and Worry About Self Subscales

Robyn Brunton, Katrina Gosper and Rachel Dryer

 Dr Robyn Brunton, Charles Sturt University, School of Psychology, Bathurst NSW

Australia 27951
 Ms Katrina Gosper, Australian College of Applied Psychology, Sydney NSW 2000
Associate Professor Rachel Dryer, Australian Catholic University, Strathfield NSW

2135

Corresponding author: Dr Robyn Brunton, Charles Sturt University, School of

Psychology, Panorama Ave, Bathurst NSW Australia 2795. Ph. 02 6338 4093, email:

rbrunton@csu.edu.au

Highlights:
 The psychometric properties of the Pregnancy-related Anxiety Scale were further
examined.
 Structural Equation Modelling confirmed the factor structure of the scale.
 The distinctiveness of pregnancy-related anxiety from state anxiety and depression
was confirmed using multiple regression.
 Evidence of convergent/divergent validity for the subscales Avoidance, Acceptance of
Pregnancy and Worry about Self was shown
 The findings from this study add to the psychometric properties of the Pregnancy-
related Anxiety Scale.
 The Pregnancy-related Anxiety Scale is a useful clinical and research tool for
pregnancy-related anxiety.
Abstract

Background: Increasingly pregnancy-related anxiety is acknowledged as a distinct

anxiety type, characterised by specific fears/worries. The Pregnancy-related Anxiety Scale

(PrAS) screens for this distinct anxiety and refinements to the scale have prompted further

1
Corresponding author: Dr Robyn Brunton, Charles Sturt University, School of Psychology, Panorama Ave,
Bathurst NSW Australia 2795. Ph. 02 6338 4093, email: rbrunton@csu.edu.au
 2

validity examination. This study aims to: replicate findings that distinguished pregnancy-

related anxiety from general anxiety/depression using the PrAS; confirm the PrAS‟s factor

structure, and examine the validity of the PrAS subscales: Acceptance of Pregnancy,

Avoidance and Worry About Self.

Methods: Pregnant women (N = 608) were recruited online and completed the PrAS,

Pregnancy Acceptance Questionnaire, Ways of Coping Questionnaire, Cambridge Worry

Scale, Parenting Sense of Competence Scale, State Trait Anxiety Inventory and the

Edinburgh Depression Scale.

Results: Multiple regression analysis confirmed general anxiety/depression

contributed little to the PrAS‟s variance, supporting the scale‟s validity and distinctiveness of

pregnancy-related anxiety. Structural equation modelling confirmed the PrAS‟s factor

structure, and the three PrAS subscales generally correlated more highly with convergent

measures than the discriminant measures.

Limitations: Limitations included the cross-sectional design of the study and the use

of some convergent/discriminant measures that lacked validity evidence for prenatal use.

Conclusions: This study provides evidence of the distinctiveness of pregnancy-related

anxiety from state/trait anxiety and depression and also adds to the psychometric properties

of the PrAS. The PrAS is a useful screening scale that can be used for antenatal screening

potentially reducing the risk of adverse outcomes associated with pregnancy-related anxiety.

The PrAS is also a useful research tool providing a more comprehensive assessment of

pregnancy-related anxiety.

Keywords

Anxiety; Pregnancy; Screening scale; Pregnancy-related anxiety; Prenatal clinical

care

Introduction
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The likelihood of experiencing anxiety increases in childbearing women due to the

significant physiological and psychological changes of pregnancy (Wenzel, 2011). Pregnant

women may experience general anxiety in pregnancy or anxiety disorders consistent with the

DSM-5 criteria. The prevalence of these anxieties, antenatally, is reported as high as 71.0%

and 39%, respectively (Leach et al., 2017b; Madhavanprabhakaran et al., 2015). These rates

are higher than those reported for women of reproductive age in the general population (e.g.

any anxiety disorder in Australian women aged 25–34 is 21.2%, ABS, 2007). In addition,

women may experience pregnancy-related anxiety, a multidimensional anxiety characterised

by pregnancy specific fears/worries (e.g. childbirth, fetal health, appearance, Bayrampour et

al., 2015). Estimates of the occurrence of pregnancy-related anxiety are varied and for

moderate levels range from around 15–90%, with the variation likely due to a lack of

consensus around definitions and measurement methods (Madhavanprabhakaran et al., 2015;

Poikkeus et al., 2006). Notwithstanding this, pregnancy-related anxiety has been identified as

a more robust predictor of maternal/fetal negative outcomes than general anxiety and DSM

anxiety disorders (see, Blackmore et al., 2016), indicating it may be a significant mental

health issue for pregnant women.

Several studies have demonstrated the distinctiveness of pregnancy-related anxiety

from general anxiety, depression and DSM anxiety disorders. Huizink and colleagues (2004)

examined 230 nulliparous women using the Pregnancy Related Anxiety Questionnaire-

Revised (PRAQ-R), an assessment of three core pregnancy-related anxiety dimensions:

childbirth, baby‟swell-being, and appearance. Measures of state/trait anxiety (State Trait

Anxiety Inventory, STAI) and depression (Edinburgh Depression Scale, EDS) were also

taken. Multiple regression analyses confirmed that combined, state/trait anxiety and

depression contributed little to the variance in the PRAQ-R, suggesting little commonality

between these constructs.

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Authors (2018b), addressed limitations of the Huizink study (e.g., including women

<15 weeks gestation) and with more detailed analyses examined the unique and combined

contribution of anxiety/depression to the PRAQ-R. Using a cross-sectional design, 1209

pregnant women completed the PRAQ-R and measures of general anxiety (Hospital Anxiety

Depression Scale) and depression (EDS). Consistent with Huizink et al., (2004),

anxiety/depression explained only a small proportion of the variance (2–23%) in the PRAQ-

R. A similar replication (N = 202, Authors, 2019b), likewise found that the contribution of

anxiety (STAI) and depression (EDS) to the PRAQ-R was low. In contrast, a significant

proportion of variance was shared between the measures of anxiety/depression and the

Perinatal Anxiety Screening Scale (PASS), designed to screen for anxiety disorder

symptomatology in pregnant women. Given that the PRAQ-R is limited in its assessment of

pregnancy-related anxiety in that it primarily focuses on three dimensions of this anxiety type

(Authors, 2015), it would seem important to replicate these results with a more

comprehensive measure of pregnancy-related anxiety (i.e. the Pregnancy-related Anxiety

Scale [PrAS], discussed below). Therefore, one of the aims of this study is to add to the

existing evidence of the distinctiveness of pregnancy-related anxiety, from general anxiety

and depression, using the PrAS.

Another study demonstrating the distinctiveness of pregnancy-related anxiety from

DSM anxiety disorders was conducted by Blackmore et al. (2016). These researchers

assessed 345 women in mid and late pregnancy on the pregnancy-related anxiety dimensions

of childbirth and fetal health. They also assessed DSM anxiety disorder symptomology (using

a structured clinical interview), general worry (Penn State Worry Questionnaire), state

anxiety (STAI) and depression (EDS). The two pregnancy-related anxiety dimensions were

predictive of negative outcomes (i.e. low birth weight, preterm birth, and postnatal mood) and

in most cases, independent of general anxiety, depression and anxiety disorders.

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Others have similarly noted associations between measures of pregnancy-related

anxiety and adverse maternal/fetal outcomes. These include, pregnancy-related anxiety being

predictive of gestational age at birth (Dole et al., 2003; Kramer et al., 2009; Mancuso et al.,

2004; Orr et al., 2007; Roesch et al., 2004; Wadhwa et al., 1993) and child developmental

outcomes, such as attention regulation and mental and psychomotor development (Huizink et

al., 2002, 2003). Pregnancy-related anxiety is also associated with unfavourable labour

outcomes such as a longer duration, unplanned caesareans and more pain relief/sedation

(Koelewijn et al., 2017; Madhavanprabhakaran et al., 2013). In contrast, these associations

are less consistent for general anxiety, thus strengthening the argument for the distinctiveness

of pregnancy-related anxiety (see Alder et al., 2007 for a review).

Given the increasing evidence to support pregnancy-related anxiety as a distinct

anxiety type; and that it has been identified as a relatively powerful and potent risk factor for

negative fetal/child outcomes (Dunkel-Schetter & Tanner, 2012, pp. 141, 146); prenatal

screening would seem advantageous to early intervention. However, much of the previous

findings, while consistent, have used scales that only assess core aspects of this specific

anxiety or lack psychometric evidence. These limitations may underestimate the occurrence

of pregnancy-related anxiety and/or the strength of the findings (Authors, 2015). Further,

current screening methods, both in Australia, America and the United Kingdom (Department

of Health, 2019; NICE, 2008; Office of Women‟s Health, 2014), do not advocate the use of a

specific scale for pregnancy-related anxiety; thus some anxious women may be undetected

(Authors, 2015) or misdiagnosed (Matthey & Ross-Hamid, 2011). Integral to robust research

findings and effective screening is a psychometrically sound scale that encompasses all

dimensions of pregnancy-related anxiety. To address the identified need for a

psychometrically sound scale for this specific anxiety (see Authors, 2015; Bayrampour et al.
 6

2015; Sinesi, Maxwell, O‟Carroll & Cheyne, 2019) the PrAS (Authors, 2019a) was

developed.

The development of the PrAS was consistent with the following definition of

pregnancy-related anxiety:

a contextually tied type of state anxiety encompassing a woman‟s fears and worries

specific to the course of the pregnancy, childbirth, the well-being of herself and the

baby, hospital, and healthcare staff, changes associated with a woman‟s appearance,

family life and the upcoming role of motherhood (Authors, 2019a, p. 4).

This definition acknowledges the most common fears and worries reported in the literature by

pregnant women. The 32-item PrAS has eight sub-scales (see appendix for the full scale)

with good to excellent internal consistency reliability (full-scale, a = .92, subscales, a = .84–

.95). To date, the scale has been demonstrated to have good psychometric properties with

content validity confirmed through development on sound theoretical, conceptual and

psychometric grounds. The PrAS has shown predictive validity by differentiating between so-

called anxious and non-anxious pregnant women (Authors, 2018a) and good construct

validity by higher correlations with convergent pregnancy-specific measures and lesser

correlations with divergent measures (Authors, 2017). In addition, Rasch analysis further

refined the scale and supported the scale‟s internal validity (Authors, 2018a). This refinement

resulted in some changes to the factor structure (the subscales Worry about Motherhood and

Anxiety Indicators were combined). Therefore, confirming the existing factor structure of the

PrAS (to ensure previous results were not sample-specific), is required and is the second aim

of this study.

Furthermore, despite the comprehensive psychometric assessment to date, further

evaluation of the subscales Acceptance of Pregnancy (Acceptance), Avoidance and Worry

 7

About Self (Worry) is needed. Previous studies were limited by the convergent measures

used for these subscales. Therefore, the third aim of this study was to address and this

limitation by establishing both convergent and divergent validity of these three subscales.

PrAS Acceptance, as the name suggests, relates to a woman‟s „acceptance‟ of her pregnancy,

which is a key developmental task. As such, this subscale should correlate strongly with

measures of pregnancy acceptance. PrAS Avoidance „taps‟ into avoidance-related behaviours

and therefore this subscale should correlate with measures of escape-avoidance. PrAS Worry

represents an assessment of a pregnant woman‟s worries and anxieties about themselves and

their proficiencies as a mother, therefore it should correlate highly with parental worry,

efficacy, anxiety and depression. For all three subscales, divergent validity will be shown

through lesser correlations with un-related measures.

This study builds on previously published work. First, to add the growing body of

evidence that pregnancy-related anxiety is distinct from general anxiety/depression, we will

replicate the work of Huizink and colleagues (2004) and our previous replications (see

Authors, 2018b; 2019b) using the more comprehensive PrAS. Measures of state anxiety, trait

anxiety and depression are predicted to contribute little to the variance of the PrAS subscales

except for PrAS Worry where the contribution will be larger. Second, given the recent

changes to the factor structure of the PrAS (see Authors, 2018a), confirmatory factor analysis

will replicate the existing factor structure. Third, we will build on previously published

psychometric evidence (Authors, 2019; a; 2018a) and examine the criterion-related validity

(i.e. convergent and discriminant) of three PrAS subscales: Acceptance, Avoidance and

Worry. Specifically, we predict:

1. PrAS Acceptance will have significantly higher correlations with the Pregnancy

Acceptance Questionnaire, in comparison to measures of state anxiety, trait anxiety,

depression and avoidance,

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2. PrAS Avoidance will have significantly higher correlations with the escape-avoidance

subscales from the Ways of Coping Questionnaire and the Cambridge Worry Scale‟s

socio-medical subscale, than measures of state anxiety, trait anxiety, depression, and

unrelated worries,

3. PrAS Worry will have significantly higher correlations with the efficacy subscale

from the Parental Sense of Competence Scale, the STAI and EDS than measures of

unrelated worry.

Method

Participants

Recruitment of 917 pregnant women occurred online. From these responses, we

retained only those with more than 80% completion of the survey (a comparison between the

complete and incomplete responses was not possible due to the large amount of missing data

for the non-completers). This resulted in a final sample of 608 respondents, aged between 18–

43 years. Online recruitment was utilised in order to reach a vast number of potential

participants, and the limitations of this recruitment methodology (e.g., bias towards younger

online users with higher education) are acknowledged (Leach et al., 2017a). Given, that our

sample was not over-represented by these specific demographic variables, and that the

sample‟s age range was consistent with childbearing years (15–44 years, Australian Institute

of Health & Welfare, 2015); we believe the sample is a good representation of the population

of interest. We acknowledge the overrepresentation of first-time mothers; however this was

not considered to affect the analyses unduly. A modest incentive encouraged survey

completion (the opportunity to win an AU$50.00 gift card).

 9

As shown in Table 1, participants were predominantly born in Australia, partnered,

tertiary educated and employed. Gestation ranged from 4–41 weeks with most women first-

time mothers in later pregnancy with no reported high risk or previous pregnancy loss.

Measures

Participants completed a 114-item online survey. Eleven demographic items sought

general (e.g. marital status), pregnancy (e.g. birth order) and pregnancy risk (including if a

medical professional has classified the pregnancy as high risk and information on previous

successful and unsuccessful pregnancies). The remaining 103 items comprised of the

following measures.

Pregnancy-related Anxiety Scale (PrAS; Authors, 2018a). The 32-item PrAS

screens for pregnancy-related anxiety with response options ranging from 1–4 (not at all to

very often). Higher scores indicate greater anxiety. The PrAS has eight subscales: Childbirth

Concerns, Body Image Concerns, Attitudes Towards Childbirth, Attitudes Towards Medical

Staff, Baby Concerns with three subscales, Avoidance, Acceptance of Pregnancy and Worry

About Self the focus of one of the aims of this study. PrAS Acceptance (3-items) taps into a

woman‟s acceptance of her pregnancy (This pregnancy is very much wanted). For this study,

two items were revised to remove the word husband consistent with current legislative

changes both in Australia and internationally (Australian Government, 2017). PrAS

Avoidance consists of 3-items focussed on avoidance behaviour (I may consider a caesarean

to avoid a vaginal birth). PrAS Worry contains 6-items assessing how a woman feels about

herself in relation to her state (Sometimes I feel panicked for no reason) and future mothering

capabilities (I worry about caring for the baby once I am home). The PrAS has excellent

internal consistency reliability for both the full-scale (α = .92) and all subscales, α = .84–.95

(Authors, 2017, 2019a).

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Pregnancy Acceptance Questionnaire (Ispa et al., 2007). This questionnaire assesses a

woman‟s ambivalence about pregnancy and the extent she is looking forward to having the

baby. Consistent with Miller et al. (2008), the 10-item scale was utilised and analysed by

subscale. The subscales consisted of: positive maternal motivation (You look forward to

teaching and caring for a new baby), negative maternal motivation (You are worried that you

do not know enough about how to take care of a baby), social reinforcement (You look

forward to telling friends about the pregnancy), and pregnancy wantedness (How glad are

you to be having this baby). In this study, responses were scored on a 5-point scale for

consistency with higher scores indicating less pregnancy acceptance. The questionnaire has

good reported internal consistency reliability, α = .69 (Ispa et al.).

Ways of Coping Questionnaire: Escape-Avoidance subscale (Folkman & Lazarus,

1985). The Ways of Coping Questionnaire contains a range of cognitive and behavioural

strategies used to manage the demands of particular situations. Respondents nominate an

event used as the focus of the responses. In this study, respondents selected if the event was

pregnancy-related or other. The 8-item Escape-avoidance Subscale provides coping

strategies for the nominated situation (Avoided being with people in general) with

participants indicating the extent the strategy was not used (0) or used a great deal (3).

Higher scores indicate greater escape/avoidance. The subscale has good internal consistency

reliability in antenatal samples, α = .71 (Kieffer & MacDonald, 2011).

Cambridge Worry Scale (CWS, Green et al., 2003). This 13-item scale assesses

pregnancy specific and general worries on a scale of 0 (not a worry) to 5 (major worry). The

CWS has four factors: Socio-medical, 4-items related to worries about hospital, birth and

coping with the baby, Socio-economic, 3-items related to money and housing, Health, 4-items

related to the mother and baby‟s health, and Relationships, 2-items focussed on relationships.

All subscales have good internal consistency reliability ranging from a = .76–.79.
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Parenting Sense of Competence Scale: Efficacy subscale (Johnson & Mash, 1989).

The Parenting Sense of Competence Scale is a measure of parenting ability. The 7-item

Efficacy subscale assesses perceived parenting self-efficacy (Being a good mother is a

reward in itself) with responses ranging from 1 (strongly disagree) to 6 (strongly agree).

Higher scores indicate greater self-efficacy. The scale was initially designed for postnatal use

but has been used antenatally (Zand et al., 2017). In the current study, one item (Considering

how long I’ve been a mother, I feel thoroughly familiar with the role) was omitted for the

inclusiveness of nulliparous women. The Efficacy subscale has good internal consistency

reliability, α = .72–.79 and construct validity with higher correlations with general self-

esteem/efficacy and parental attitudes and lesser correlations with mood measures (Johnson

& Mash; Karp et al., 2015).

State-Trait Anxiety Inventory (STAI; Spielberger et al., 1970). The original 40-item

STAI comprises of a state anxiety subscale (STAI-S, measures how respondents feel “at this

moment” [I am tense]) and a trait anxiety subscale (STAI-T, measures how you generally feel

[I feel nervous and restless]). Response options are on a four-point scale (state anxiety from

not at all [1] to very much so [4] and trait anxiety from almost never [1] to almost always

[4]). Higher scores indicate greater anxiety. In this study, the abridged 16-item version of the

scale was utilised (Van Knippenberg et al., 1990). This version has the advantage of brevity

while retaining good psychometric properties (α = .84–.86).

Edinburgh Depression Scale (EDS; Cox et al., 1987). The 10-item EDS assesses

depression in pregnancy. The items relate to how the respondent has felt in the past week (I

have felt sad or miserable) with varied response options ranging from 0–3. Higher scores

indicate higher levels of depressive symptoms. Matthey, Henshaw, Elliott and Barnett (2006)

recommend a cut-off score of 15 for screening for antenatal depression. The EDS has been

validated antenatally with good internal consistency reliability (α = .84) and satisfactory
 12

screening validity for antenatal depression (Bergink et al., 2011; Cox et al.; Murray & Cox,

1990).

Procedure

Following institutional ethics approval (Approval Number = 408160518), Facebook

advertising promoted the survey. This method can reach a large number of potential

participants with online responses not significantly different from traditional paper/pencil

methods (Weigold et al., 2013). Participants accessed the survey via a hyperlink and

completion indicated informed consent. All participants first completed the PrAS, followed

by randomised convergent/discriminant measures and ending with the demographic

questions. Following completion, participants were directed to a separate webpage (to

maintain the anonymity of responses) for entry to the gift card draw.

Data Analyses

Data was analysed using the IBM Statistical Package for the Social Sciences, version

23. Cronbach‟s alpha assessed internal consistency reliability as: .70–.79 = moderate; .80–.89

= moderately high; .90+ = excellent (Murray & Davidshofer, 2005). Normality was assessed

using the Shapiro-Wilk statistic and visual inspection of histograms. List-wise deletion was

utilised for all analyses to maximise statistical power.

Multiple Regression Analyses

Eight multiple regression analyses determined the amount of variance accounted for

in the PrAS subscales (outcome variables) by anxiety and depression (predictor variables).

Multicollinearity was assessed based on Field‟s (2013) guidelines: rs <.80, variance inflation

factor < 10; and tolerance > .02 indicated multicollinearity was not problematic. Adjusted R2

assessed the combined contribution of the predictors to the criterion variables and squared

semi-partial correlations (sr2) provided the unique variance explained by each predictor. All
 13

regression analyses were completed using 1000 bootstrapped resamples and 95% bias-

corrected and accelerated (BCa) confidence intervals. BCa confidence intervals are adjusted

in the bootstrap distribution for both bias and skewness and considered more accurate (Field,

2013).

Confirmatory Factor Analysis

Confirmatory factor analysis was performed using structural equation modelling

(SEM). Model fit was evaluated using the Standardised Root Mean Residual (SRMR), Root

Mean Square of Approximation (RMSEA), Comparative Fit Index (CFI) and Tucker Lewis

Index (TLI). A good fitting model was evidenced by an SRMR close to .08, an RMSEA close

to .06, a CFI and TLI close to .95 (Hu & Bentler, 1998). It should be noted that for sample

sizes > 400, the chi-square statistic is not recommended as a measure of goodness of fit. This

is due to the probability of rejecting the model reducing as a function of sample size (Kenny

& McCoach, 2003). Therefore consistent with published recommendations, the model fit was

determined by the fit indices above (Bentler & Bonett, 1980; Kenny & McCoach, 2003). The

factor structure of the PrAS was the model tested.

Criterion-related validity

Spearman‟s Rho correlations were utilised given the ordinal nature of the data.

Correlations were completed using 1000 bootstrapped resamples and 95% BCa confidence

intervals. Correlations were evaluated as small (r ≤ .40), medium (r = .41–.54), large (r =

.55–.70) and very large (r ≥ .71) (Sattler, 2008). Significant differences between correlation

coefficients were determined using Fisher‟s r to z transformation.

Results

Preliminary analyses
 14

List-wise deletion maximised the remaining sample size and non-normality of some

variables was addressed by the non-parametric methods and bootstrapping (Field, 2013). All

reverse-scored items were re-coded (i.e. PrAS 6-items, Pregnancy Acceptance 9-items, EDS,

2-items, STAI-S, 4-items, STAI-T 4 items).

Given that high risk pregnancy was reported by 150 women (24.7%), the influence of

this variable was assessed. All correlations between the PrAS subscales and all

convergent/discriminant measures were compared for the high-risk group and the remaining

sample for any significant difference. Analyses confirmed no statistically significant

differences between these correlations, therefore high-risk participants were retained in all

analyses.

Descriptive statistics and reliability

Table 2 presents the descriptive statistics and internal consistency reliability for all

measures. The full-scale PrAS had excellent reliability, and all PrAS subscales exceeded the

preferred cut-off (α = .80) for tests used in individual assessment (Sattler, 2008). Inspection

of item-total statistics for all PrAS subscales confirmed the deletion of any individual items

would not substantially improve any subscale‟s reliabilities. However, one item from

Attitudes Towards Medical Staff, (I don’t know if I can ask the midwives/doctors anything) if

removed would marginally improve the subscale‟s reliability (from a = .94 to .97). However,

given the subscale‟s already excellent reliability, this was likely a sample-specific effect. The

reliability for all convergent/divergent measures was good and lower reliabilities mainly seen

for subscales with fewer items (i.e. 2-items).

Multiple Regression

Eight multiple regression analyses determined the amount of variance accounted for

in the PrAS subscales by measures of state/trait anxiety and depression. Age and gestation
 15

were included as predictor variables based on their inverse relationship with some PrAS

subscales (age and PrAS Childbirth Concerns, Worry, Body Image, Attitudes Towards

Medical Staff, rs = -.09 to -.16, p = <.05; gestation and PrAS Attitudes Towards Childbirth,

Baby Concerns and Attitudes to Medical Staff, rs = -.21 - -.13, p = < .001). Correlations

between the remaining predictor variables were very large (rs = .73–.75, p < .01), however

multicollinearity was not problematic according to Field‟s (2013) guidelines.

Table 3 presents the full regression results. As shown, all models were statistically

significant. Age accounted for a small significant amount of variance in PrAS Body Image

and Attitudes Towards Medical Staff (< 1%). Gestation similarily accounted for a small

amount of unique variance in PrAS Attitudes Towards Childbirth, Worry, Baby Concerns and

Attitudes Towards Medical Staff, ranging from 0.6% to 3.2%. Except for PrAS Worry and

Body Image, anxiety/depression explained no more than 14% of the variance in the

remaining PrAS subscales. State anxiety contributed uniquely to most PrAS subscales except

Childbirth Concerns and Attitudes Towards Medical Staff. Trait anxiety likewise uniquely

contributed to all subscales except Childbirth Concerns, Acceptance and Avoidance.

Depression made unique contributions to Childbirth Concerns and Body Image, only. As

expected, the combined and unique contribution of anxiety and depression to PrAS Worry

was very large and consistent with the focus of this subscale. In response to the reviewers‟

comment, we also included the concurrent and discriminant measures as predictors for the

relevant PrAS subscales (i.e., Acceptance, Avoidance and Worry). As expected the

concurrent measures contributed more to the variance of the respective subscales whereas the

discriminant measures did not (except for the escape-avoidance subscale, likely due to the

reasons stated above). The results are not reported here and available as supplementary data.

Confirmatory Factor Analysis

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SEM confirmed the eight-factor structure of the PrAS (see Figure 1). Nineteen cases

with missing data were deleted, resulting in an adequate sample of N = 589 (Tabachnick &

Fidell, 2001). The majority of correlations were >.30 and the Kaiser-Meyer-Olkin measure of

sampling adequacy (p = .873) and Bartlett‟s Test of Sphericity (χ2(496) = 11818.919, p <

.001) confirmed data suitability (Allen et al., 2014). The ensuing model (χ2(437) = 1178.79, p

< .001) was considered a good fit evidenced by the fit indices (SRMR = .049, RMSEA =

.054, CFI = .936, TLI = .927). Examination of the modification indices confirmed that further

model refinement would not substantially improve the model fit.

Criterion-related validity

Non-Parametric Correlations

As predicted and presented in Table 4, significant correlations ranged from small to

large between PrAS Acceptance and the parental acceptance subscales. Correlations with

most discriminant measures (anxiety, escape-avoidance and depression) were all small,

positive and significantly lower than correlations with convergent measures.

There were small, significant and positive correlations between PrAS Avoidance and

the convergent measures of Escape-avoidance subscale, and the CWS Health and Socio-

Medical subscales (i.e., subscales that focus on birth/hospital worries). All correlations with

the discriminant measures (state/trait anxiety, depression, and acceptance) were significantly

lower in comparison to the correlations with convergent measures. One exception was the

Escape-avoidance subscale, and this was further investigated by comparing the group who

nominated a pregnancy-related event (n = 260) and the other group (n = 331). As shown

below, the other group had a significant positive correlation with PrAS Avoidance, whereas

the pregnancy-related group‟s correlation was not significant.

 17

Construct validity for PrAS Worry was demonstrated by significant positive

correlations with parental worry (CWS Health and Socio-medical Subscales), and measures

of anxiety and depression, all ranging in size from small to large. The efficacy subscale also

had a significant negative correlation with PrAS Worry, indicating that women with a less

sense of parenting competence had higher PrAS Worry scores. Most of the correlations with

the convergent measures (i.e., health/medical worry, competence, anxiety and depression)

were significantly higher than the measures of unrelated worry (i.e., coping and acceptance).

Discussion

This study had three aims: to replicate the findings of the Huizink study, confirm the

eight-factor structure of the PrAS, and evaluate the psychometric properties of the three PrAS

subscales: Acceptance, Avoidance and Worry. As predicted, the contribution of anxiety and

depression to the variance of the PrAS was low (except for PrAS Worry) thereby supporting

pregnancy-related anxiety as a distinct anxiety type. SEM confirmed the current structure of

the PrAS, and as predicted PrAS Acceptance, Avoidance and Worry generally demonstrated

stronger correlations with convergent than discriminant measures, consistent with the

underlying principle of construct validity (Campbell & Fiske, 1959).

The Distinctiveness of Pregnancy-related Anxiety

The contribution of measures of state/trait anxiety, depression, age and gestation to

the variance of the PrAS was small and the unique contributions, very small (PrAS Worry

excepted). The larger combined contribution to the variance (of the predictors) for PrAS

Worry was expected and consistent with the focus of this subscale. Similarly, for PrAS Body

Image, the larger contributions of the predictors are consistent with anxiety/depression‟s

associations with body image (Silveira et al., 2015). These results replicate previous studies

utilising the PRAQ-R (Authors, 2018b, 2019b). In addition, given these analyses have only
 18

been conducted using the PRAQ-R, the fact that the PrAS also replicated these findings

provides additional validity evidence for this scale. Taken together, these results that general

anxiety and depression have low commonality with pregnancy-related anxiety, support the

proposition that pregnancy-related anxiety is a distinct type of anxiety. The contribution of

age and gestation, while signifcant for some subscales, was low with very small Beta values

(none exceeding .10) and the unique contribution to the variance was less than 1% for age

and 3.5% for gestation. These values indicate that age and gestation may influence

pregnancy-related anxiety but their impact is low.

Criterion-related validity

PrAS Acceptance

Stronger correlations between PrAS Acceptance and measures of pregnancy

acceptance provide evidence of convergent validity. The strongest correlation was with

pregnancy wantedness, which is a crucial component of pregnancy acceptance (Lederman,

2009). Further, the unique but small contribution of state anxiety to the variance of PrAS

Acceptance is likely due to the association of this construct with an unplanned/ unwanted

pregnancy. One review identified unplanned/unwanted pregnancy as a significant risk factor

for antenatal anxiety/depression (Biaggi et al., 2016). Interestingly, an identified

characteristic of less pregnancy acceptance is depression during pregnancy, and this may

account for some of the variance in the discriminant measure (i.e., depression).

Notwithstanding this, the correlations for the discriminant measures (anxiety, depression and

escape-avoidance) were lower and support the discriminant validity of PrAS Acceptance.

Similarly, the regression results confirmed that the contribution of anxiety/depression to this

subscale‟s variance was minimal.

PrAS Avoidance
 19

As expected, PrAS Avoidance correlated higher with measures of worry (i.e., those

focused on the baby, childbirth, hospital and postnatal care) and lower with measures of

anxiety, depression and parenting self-efficacy. This finding is also consistent with

anxiety/depression accounting for only a small amount of variance in the scores of this

subscale. An unexpected finding was the small correlation between PrAS Avoidance and

Escape-avoidance. While the correlation was in the expected direction, the magnitude of the

correlation was smaller than expected.

Further examination of the data indicated that there was a larger correlation between

PrAS Avoidance and Escape-avoidance for those who indicated their escape-avoidance was

unrelated to pregnancy (i.e., other) in comparison to participants who nominated a

pregnancy-related event. This finding suggests that the item content of the Escape-Avoidance

scale may lack validity for a specific context such as pregnancy. Indeed, items such as

Refused to believe it had happened may be more relevant for non-pregnancy „events.‟ Also,

given that avoidance coping behaviour decreases as pregnancy progresses (Hamilton &

Lobel, 2008) the result may reflect sample-specific characteristics with over 40% of the

participants in late pregnancy. Regardless, Avoidance remains an important dimension of

pregnancy-related anxiety especially given that fear of childbirth is strongly associated with a

preference for a caesarean (consistent with the positive correlations between PrAS

Avoidance and both PrAS childbirth subscales, Størksen et al., 2015). Considering that fear

of childbirth has a reported prevalence ranging from 4.5–15.6% in European countries

(Lukasse et al., 2014; Størksen et al., 2012) and as high as 27% in Australian and American

samples (Fenwick et al., 2009; Stoll et al., 2015), the importance of this scale should not be

underestimated.

PrAS Worry
 20

As expected, PrAS Worry correlated strongly with the convergent measures of

anxiety, depression, worry and efficacy (consistent with items such as I worry about caring

for the baby once I am home). The largest correlations were with the CWS subscales

focussing on baby‟s health and mothering. The contribution of anxiety and depression to this

subscale was also evident with large contributions from anxiety/depression (combined and

unique) to the subscale. This large contribution to PrAS Worry is consistent with the scale

assessing a woman‟s state, which includes anxiety indicators and future orientated concerns.

The similar contribution of depression is likely due not just to the high comorbidity of

anxiety and depression (up to 85%, Gorman, 1997) but also the existence of the distinct

anxiety subscale within the EDS (the correlation of this subscale with PrAS Worry was

r=.65, p<.001). As expected, there were lower correlations with the discriminant measures of

unrelated worries (finances, relationships).

The importance of PrAS Worry is its focus on somatic symptoms. Bayrampour et al.

(2016) argue that somatic symptoms are a critical attribute of the concept of pregnancy-

related anxiety. Similarly, Authors (2015) argue that the importance of including non-

confounding physical symptoms of anxiety in pregnancy-related anxiety measures, was

previously under-recognised.

Implications for clinical practice and research

The development of the PrAS and its accumulating psychometric evidence has

implications for both clinical and research use. Clinically, the PrAS is a useful screening tool

for identifying women with pregnancy-related anxiety, potentially providing valuable

opportunities for intervention. While the separate interpretation of the subscales, especially in

clinical settings, should be cautiously done, higher scores may offer insights into a woman‟s

well-being and specific areas of concern. With the increasing use of midwife-led continuity

of care models both in Australia and overseas (Homer, 2016), the opportunity these provide
 21

to establish trust relationships between midwives and expectant mothers cannot be

underestimated (Sandall, Soltani, Gates, Shennan & Devane, 2016). Screening tools such as

the PrAS used as part of a comprehensive psychosocial assessment can assist in identifying

those at risk, with midwife relationships characterised by concern and empathy known to be

valued more by pregnant women (Rollans, Schmeid, Kemp & Meade, 2013). The use of tools

such as the PrAS during these assessments provide specific information on areas of concern

and the possibility of more targeted interventions. Studies are currently underway to provide

further data on cut-off scores and also to investigate the validity of a short-form of the PrAS,

which would be more conducive to busy clinical settings.

The PrAS also has utility in research settings by providing researchers with a means

of quantifying pregnancy-related anxiety not previously available. The ordinal to interval

transformations bring more precision to the analysis as parametric tests can be used with

confidence (see, Authors, 2018a for further details).

Limitations and Future Directions

Limitations of this study include the cross-sectional design and further studies using

longitudinal data will enable more causal investigation. Also, assessment of high-risk

pregnancy was limited by self-report, which did not enable a comprehensive evaluation.

Future studies should seek to evaluate this risk better to assess its influence on pregnancy-

related anxiety. Some of the response variability seen in some measures is expected given the

scale‟s clinical nature and the non-clinical sample. While clinical samples are not required for

the assessment of concurrent validity, it would be useful to examine how the PrAS performs

in differentiating between women who have been given a clinical diagnosis from those who

have not (the current authors are currently conducting studies to investigate this). A number

of the convergent/discriminant measures also lacked antenatal validity but were used given
 22

that validated measures for this unique population could not be located. Future studies should

seek to address this.

Conclusion

This study adds to the psychometric properties of the PrAS and specifically supports

the reliability, internal validity and construct validity of the scale. Further, it provides

evidence supporting the distinctiveness of pregnancy-related anxiety from state/trait anxiety

depression. The utility of the PrAS is evident not only as a research tool but also as a scale for

improving early clinical antenatal screening. Improved early screening and targeted

interventions for expectant mothers experiencing high levels of pregnancy-related anxiety,

may contribute to reducing the risk of adverse outcomes for both mother and baby.

Role of Funding Source

Partial funding was received from the Australian College of Applied Psychology. The
funding source had no role in the study design, collection of data, analysis or interpretation,
the writing of the review or the decision to submit the article for publication.
a
Charles Sturt University, School of Psychology, Bathurst NSW 2795, Australia.
b
Australian College of Applied Psychology, Sydney NSW 2000.
c
Australian Catholic University, Strathfield Campus, NSW 2135, Australia.

Declaration of Competing Interest

none.
Acknowledgements

This research was completed as part requirements of Ms Gosper‟s Honours thesis.

We acknowledge the women who voluntarily gave their time to participate in the online

survey. Without their contribution, this study would not be possible.

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Figure 1. SEM model

Table 1
 31

Participant Demographics

Age M ( SD) a 27.59 (5.35, N=581)

Marital status b

Married/Defacto 534 (88.0)

Single 52 (8.6)

Other 21 (3.4)

Education b

High School 149 (24.5)

TAFE (trade certificates, diplomas) 217 (35.7)

University (undergrad) 157 (25.8)

University (postgrad) 85 (14.0)

Employment b

Employed 45 (75.1)

Homemaker 116 (19.1)

Unemployed 26 (4.3)

Student 6 (1.0)

Carer 3 (0.5)

Country of Birth d 541 (89.4)

Australia 15 (2.5)

United Kingdom 7 (1.2)

New Zealand 4 (0.7)

Ireland 3 (0.5)

South Africa 3 (0.5)

Lebanon 32 (5.2)

Other
 32

Gestation (4-41 weeks) 115 (18.9)

Early pregnancy (0–13 weeks) 236 (38.8)

Mid pregnancy (14–26 weeks) 257 (42.3)

Late pregnancy (27+ weeks)

Parity 414 (68.1)

Primiparous 194 (31.9)

Multiparous

High Risk e 150 (24.7)

Yes 458 (75.3)

No

Note. Percentages reported in parentheses. Missing values a=27, b=1, c=2, d=3, e=7

Table 2
Descriptive Statistics and Internal Consistency Reliability
Variable Means Ran I Sampl
ge CR e size

PrAS 64.22 32- . 589

(15.22) 128 91

Childbirth Concerns 11.83 6-24 . 607

(4.27) 84

Body Image Concerns 11.48 5-20 . 606

(4.33) 90

Attitudes Towards Childbirth 8.44 3-12 . 603

(2.38) 84

Worry About Self 11.74 6-24 . 606

(3.95) 85

Baby Concerns 6.43 3-12 . 605

(2.70) 92

Acceptance of Pregnancy 3.85 3-12 . 605

 33

(1.56) 82

Avoidance 4.59 3-12 . 607

(2.40) 90

Medical 5.92 3-12 . 606

(2.74) 94

Pregnancy Acceptance Questionnaire 20.15 10- . 607

(5.33) 50 75

Positive Maternal Motivations 4.51 3-15 . 608

(1.79) 80

Negative Maternal Motivations 8.83 3-15 . 608

(2.57) 54

Social Reinforcement 3.43 2-10 . 607

(1.67) 75

Pregnancy Wantedness 3.04 2-10 . 608

(1.55) 56

Escape-Avoidance Subscale 8.51 0-24 . 608

(4.82) 76

Cambridge Worry Scale 24.13 0-65 . 607

(12.49) 84

Socio-medical 7.81 0-20 . 608

(5.08) 78

Socio-economic 5.78 0-15 . 607

(4.01) 73

Health 8.24 0-20 . 608

(4.67) 61

Relationships 2.31 0-10 . 608

(2.57) 62

Efficacy Subscale 26.42 6-36 . 608

(6.14) 83

State Anxiety 17.07 8-32 . 602

 34

(5.30) 88

Trait Anxiety 19.17 8-32 . 606

(4.81) 85

Depression 11.23 0-30 . 604

(6.01) 90

Note: PrAS=Pregnancy-related Anxiety Scale, Medical=Attitudes Towards Medical Staff. ICR=internal

consistency reliability with Cronbach‟s alpha statistic reported. Standard deviation reported in parentheses. Range=actual
possible range of scores

Table 3
Multiple Regression Analyses
Criterion Variable Predic R Β CIs for P F (4,
2
tors B art r 563)

PrAS Childbirth . 19.3

14 2***

Age - -0.10– -
.04 0.02 .05
STAI-
S . -0.01– .0
11* 0.22 8*
STAI-
T . -0.06– .0
06 0.17 4
EDS
. 0.04– .1
Gestati
14** 0.25 2**
on
. -0.01– .0
03 0.06 6

PrAS Body Image . 47.6

27 7***
 35

Age - -0.12– - -
.07* 0.01 .08*
STAI-
S . 0.04– .1
15** 0.26 1**
STAI-
T . 0.03– .1
16** 0.28 1**
EDS
. 0.05– .1
Gestati
15** 0.23 2**
on
. -0.01– .0
03 0.06 7

PrAS Attitudes . 17.9

Towards Childbirth 13 3***

Age . -0.03– .0
01 0.04 1
STAI-
S . 0.05– .1
11** 0.17 4**
STAI-
T . 0.01– .0
07* 0.13 8*
EDS
. -0.05– .0
Gestati
01 0.06 1
on
- -0.04– - -
.02* 0.01 .08*

PrAS Worry About . 134.

Self 54 58***

Age . -0.03– .0
02 0.06 2
STAI-
S . 0.04– .0
12** 0.19 9**
STAI-
T . 0.16– .1
24*** 0.31 8***
EDS
. 0.17– .2
Gestati
24*** 0.30 2***
on
. 0.01– .0
03** 0.06 8**

PrAS Baby . 22.5

Concerns 16 9***
 36

Age . -0.01– .0
03 0.06 5
STAI-
S . 0.01– .0
08* 0.15 9*
STAI-
T . 0.07– .1
14*** 0.21 5***
EDS
- -0.07– -
Gestati
.01 0.05 .01
on
- -0.07– - -
.05*** 0.03 .18***

PrAS Acceptance . 12.2

of Pregnancy 09 0***
Age . -0.01– .0
02 0.05 7
STAI-
S . 0.06– .2
10*** 0.14 0***
STAI-
T - -0.06– -
.02 0.03 .04
EDS
. -0.03– .0
Gestati
01 0.04 1
on
. -0.01– .0
01 0.02 4

PrAS Avoidance . 4.25

03 **
Age . -0.01– .0
03 0.07 6
STAI-
S . 0.01– .0
06* 0.12 8*
STAI-
T - -0.08– -
.01 0.05 .02
EDS
. -0.03– .0
Gestati
03 0.09 4
on
- -0.03– -
.01 0.01 .05

PrAS Medical . 19.6

14 2***
 37

Age - -0.07– - -
.04 0.01 .07
STAI-
S . -0.02– .0
05 0.13 6
STAI-
T . 0.02– .1
10* 0.18 1*
EDS
. -0.02– .0
Gestati
05 0.11 6
on
- -0.06–- -
.03** 0.01 .11**

Notes: PrAS = Pregnancy-related Anxiety Scale, PrAS Medical= PrAS Attitudes Towards Medical Staff, , STAI-S
= State Trait Anxiety Inventory-State Subscale, STAI-T = State Trait Anxiety Inventory-Trait Subscale, EDS= Edinburgh
Depression Scale. R2 = adjusted R2, B = unstandardised beta, CIs=Confidence Intervals, Part r = semi-partial correlation,
when squared represents unique variance accounted for, not based on bootstrapping. Asterisk denotes significance levels
with *p < .05, **p < .01, ***p < .001.

Table 4
Non-Parametric Correlations
PrAS PrAS PrAS
Acceptance Avoidance Worry

PrAS Avoidance .081

PrAS Worry .239** .171**

Pregnancy Acceptance .514**† .099* .471**

PMM .497**† .005 .271**

NMM .166** .109** .474**

SR .434**† .081* .248**

PW .554**† .079 .252**

CWS

Socio Economic .201** .101* .401**

Relationships .339** .091* .402**

Health .056 .211** .443**

 38

Socio Medical .245** .206** .542**

Ways of Coping

Escape-Avoidance .191** .122** .512**

Pregnancy-related .184 -.005 .512**

Other .201** .214** .519**

Parenting Sense of
Competence

Efficacy -.274** -.104* -

.350**†

STAI-S .339** .180** .627**

†

STAI-T .261** .124*** .663**

†

EDS .259** .167** .689**

†

Note. Pregnancy Acceptance=Pregnancy Acceptance Questionnaire, PMM=Positive Maternal

Motivation, NMM=Negative Maternal Motivation, SR=Social reinforcement, PW=Pregnancy Wantedness,
CWS=Cambridge Worry Scale, STAI-S=State-Trait Anxiety Inventory, State Subscale, STAI-T=State-Trait
Anxiety Inventory, Trait Subscale, EDS=Edinburgh Depression Scale. N = 581. Asterisk indicates
significance levels: **p < .01, ***p < .001, two-tailed. Convergent correlations are in bold. † indicates that
the convergent correlation is significantly different from the largest discriminant correlation (using Fishers r
to z transformation).