The rate of pre-eclampsia in Indonesia is the second highest cause of maternal death after bleeding. Death caused by pre-eclampsia is 3-10% in the world and 9.8-25% in Indonesia [1]. Pre-eclampsia is a complication of pregnancy and childbirth which is characterized by an increase in blood pressure, urine protein and edema, sometimes accompanied by complications until coma [2,3] . This condition will bring harmful effects on the mother and fetus if not treated quickly and will lead to death. Some comorbidities will increase the prevalence of pre-eclampsia [4]. 

Hypertensive disorders of pregnancy (HDP), especially pre-eclampsia, can lead to long-term complications, such as cardiovascular disease [5,6]. Research conducted in developed countries shows that women who have experienced pre-eclampsia have higher levels of anxiety and depression, have more cognitive problems when completing daily routines and a lower quality of life, than women with normal pregnancies [7]. Pregnant women with pre-eclampsia are reported to have more symptoms associated with post-traumatic stress disorder (PTSD) after several years postpartum [8-10].

Based on several studies on anxiety, it is found that it had an effect on increasing maternal blood pressure [11-13]. The results also found that there were 13 subjects (44%) experiencing multigravida anxiety levels accompanied by hypertension and 15 subjects (56%) did not experience it accompanied by hypertension. 15 subjects (48%) experienced primigravida with hypertension and 16 subjects (52%) experienced it without hypertension, these results were performed with the Mann Whiteney test p 0384> 0.05. The results of a study conducted by Hasmawati [14], showed that respondents (76.2%) with comorbidities experienced higher pre-eclampsia than those 23.8% respondents without comorbidities [14]. Hypertension was one of the factors that affected anxiety. Anxiety can cause the increase of the sympathetic nervous system, changes in blood pressure, heart rate, breathing with skin color and if not treated immediately it will increase anxiety, tension, fear and stress [11,15,16].

This study aims to find out the characteristics of pregnant women including of maternal age, gestational age and parity and anxiety levels experienced by pregnant women. In addition, this study analyzes the correlation between demographic factors and anxiety levels of pregnant women with pre-eclampsia.    

The population in this study were all pregnant women in Public Health Center in Banjarnegara District. This study was recruited 55 respondents. Purposive Sampling was used for the sampling technique with the inclusion criteria were pregnant women in their third trimester who were willing to be respondents and could read and write. The exclusion criteria were the mothers with heart disease and disease complications. 

The Zung Self-Rating Anxiety Scale (SAS/SRAS) was used to measure the level of anxiety. Zung Self-Rating Anxiety Scale is an anxiety assessment designed by William WK Zung. This questionnaire was translated to Indonesian language [17]. Anxiety symptoms was developed based on in the Diagnostic and Statistical Manual of Mental Disorders (DSM-II). The aassessment was based on a Likert scale of 1-4, where a score of 4 illustrates negative things with an assessment: very rarely (1), sometimes (2), often (3), always (4). This questionnaire consisted of 20 statements, consisting of 5 symptoms for attitude and 15 statements for somatic symptoms. This questionnaire has been modified and tested for validity and reliability using a significant level of 95%, then if r count> r table (0.444), then the measurement was considered valid. Univariate test was used to see the limits of respondent characteristics and bivariate analysis test was used to analyze the effect of anxiety levels on pre-eclampsia prevalence. Demographic sheets, as one of the instruments in this study, were used to see the characteristics of respondents from maternal age, maternal gestational age and number of pregnancies or parity.

Respondent Characteristics

The results of this study were used to find out the characteristics of respondents in this study in the Table 1.

Table 1: Characteristics of Respondents based on Maternal Age, Gestational Age and Parity (n = 55)

Based on Table 1, it shows that the majority of respondents or 9 (22%) who experienced pre-eclampsia were between 20-35 years old. There were were 5 respondents (21.7%) who experienced pre-eclampsia at the age of 8 months of gestational age. The majority of people or 5 respondents (18.5%) experienced pre-eclampsia in multigravida.

Mother’s Anxiety Level

The results of the anxiety level obtained scoring described in the Table 2,3.

Based on Table 2,3, it was found that the results of the Tables showed that the majority or 46 respondents (83.6%) were at the normal level of anxiety. The majority of pre-eclampsia in the normal category were 46 respondents (83.6%).

Table 2: Frequency Distribution of Anxiety Levels and Pre-Eclampsia in Pregnant Women (n = 55)

The Correlation Between Anxiety of Pregnant Women and The Prevalence of Pre-Eclampsia

The results of this study on the effects of anxiety levels on Pre-eclampsia prevalence show that from 55 people as samples, there were 46 respondents with normal anxiety, 44 respondents did not experience pre-eclampsia and the other 2 experienced pre-eclampsia. While 9 respondents experienced mild anxiety, 2 respondents did not experience pre-eclampsia and 7 respondents experienced pre-eclampsia. Chi Square test results obtained p value of 0,000 which is smaller than a = 0.05, meaning that Ho is rejected and Ha is accepted so that it can be concluded that there is a relationship between anxiety levels and the Pre-eclampsia prevalence in 3rd trimester pregnant women in the working area of Purwanegara health center.

Table 3: The Correlation Between Anxiety of Pregnant Women and The Prevalence of Pre-Eclampsia

This study obtained the characteristics of respondents who experienced pre-eclampsia, one of them showed that 9 respondents (22%) were between 20-35 years old. Age as one of the factors of the effects of pre-eclampsia is also mentioned previous research [18-20]. Mother’s age on asphyxia, birth weight infants against asphyxia in mothers with severe pre-eclampsia. The independent variable gestational age and infant birth weight had a significant effect simultaneously on the dependent variable asphyxia. The age of the mother is more than 35 years so there have been changes in the body due to aging of the organs and resulted in getting diseases in pregnancy related to age will increase, such as high blood pressure, pregnancy poisoning (pre-eclampsia/eclampsia), diabetes, heart and blood vessel disease. But the incidence of pre-eclampsia does not rule out the possibility of occurring at the age of 20-35 years, as in the results of this study the highest amount of pre-eclampsia at the age of 20-35 [21].

There were 5 respondents (21.7%) who experienced pre-eclampsia at the age of 8 months. This research was conducted in Permata Bunda Purwodadi Hospital with a case group of mothers with pre-eclampsia whose babies were diagnosed with asphyxia totaling 32 samples and a control group of severe pre-eclampsia mothers whose babies were not diagnosed with asphyxia totaling 48 samples. It was found that the increasing age of pregnancy means an increase in pregnancy organ performance so that it affects the work of the heart which results in increased blood pressure [22].

There were 5 respondents (18.5%) who experienced pre-eclampsia in multigravida. This study similar with previous study that mothers who had primigravida and multigravida parity (first child pregnancy and pregnancy with 4 children) had a 4.21 times chance of experiencing pre-eclampsia compared to mothers of parity not at risk [23-25]. 

This study has an influence between the level of anxiety on the prevalence of pre-eclampsia supported by other studies conducted by Elsanti et al. [11], of 64 respondents as many as 7 respondents (10.9 %%) experienced pre-eclampsia and as many as 57 respondents (89.1%) did not experience pre-eclampsia. The level of anxiety causes the heart muscle to work and spikes the blood pressure [15]. This is in line with the research conducted regarding the relationship of stress levels with pre-eclampsia events where the result of stressed mothers has a significant relationship with pre-eclampsia [8,26,27].

This study found that there was an effect of anxiety level with pre-eclampsia. Furthermore, the nurses were expected to play an active role in providing counseling about pre-eclampsia risk pregnancies. This can be done by conducting health education about the importance of conducting pre-pregnancy checks during pregnancy routinely, especially pre-eclampsia pregnant women, by advocating for pregnancy exercises as a form of therapy to reduce anxiety and by suggesting to the family to provide support to pre-eclampsia pregnant women both material and spiritual.

1. Anggraini, A.B. “Young mothers, (Pre-)eclampsia and other factors related to preterm birth in two hospitals in Jakarta.” KnE Life Sciences, 2018, pp. 85–91.

2. Bilano, V.L. et al. “Risk factors of pre-eclampsia/eclampsia and its adverse outcomes in low- and middle-income countries: A WHO secondary analysis.” PLOS ONE, vol. 9, no. 3, 2014, e91198. https://doi.org/10.1371/journal.pone.0091198.

3. Phipps, E.A. et al. “Pre-eclampsia: Pathogenesis, novel diagnostics and therapies.” Nature Reviews Nephrology, vol. 15, no. 5, 2019, pp. 275–289.

4. Kiondo, P. et al. “Risk factors for pre-eclampsia in Mulago hospital, Kampala, Uganda.” Tropical Medicine & International Health, vol. 17, no. 4, 2012, pp. 480–487.

5. Karumanchi, S.A. and J.P. Granger. “Preeclampsia and pregnancy-related hypertensive disorders.” Hypertension, vol. 67, no. 2, 2016, pp. 238–242.

6. Veerbeek, J.H. et al. “Cardiovascular disease risk factors after early-onset preeclampsia, late-onset preeclampsia and pregnancy-induced hypertension.” Hypertension, vol. 65, no. 3, 2015, pp. 600–606.

7. English, F.A. et al. “Risk factors and effective management of preeclampsia.” Integrated Blood Pressure Control, vol. 8, 2015, pp. 7–12.

8. Hoedjes, M. et al. “Symptoms of post-traumatic stress after preeclampsia.” Journal of Psychosomatic Obstetrics & Gynecology, vol. 32, no. 3, 2011, pp. 126–134.

9. Roberts, L. et al. “Depression, anxiety and post-traumatic stress disorder following a hypertensive disorder of pregnancy: A narrative literature review.” Frontiers in Cardiovascular Medicine, vol. 6, 2019, p. 147. https://doi.org/10.3389/fcvm.2019.00147.

10. Vignato, J. et al. “Post-traumatic stress disorder in the perinatal period: A concept analysis.” Journal of Clinical Nursing, vol. 26, no. 23–24, 2017, pp. 3859–3868.

11. Elsanti, D. and N. Sumarmi. “The effect of stress and social support among postpartum depression women in Indonesia.” GSTF Journal of Nursing and Health Care (JNHC), vol. 3, no. 2, 2016.

12. Glover, V. “Maternal depression, anxiety and stress during pregnancy and child outcome: What needs to be done.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 28, no. 1, 2014, pp. 25–35.

13. Maniam, J. and M.J. Morris. “Long-term postpartum anxiety and depression-like behavior in mother rats subjected to maternal separation are ameliorated by palatable high fat diet.” Behavioural Brain Research, vol. 208, no. 1, 2010, pp. 72–79.

14. Hasmawati, D. “Faktor-Faktor yang Berhubungan dengan Kejadian Pre Eklampsi pada Kehamilan di RSUD Embung Fatimah Kota Batam Tahun 2012.” Jurnal Kesehatan Andalas, vol. 3, no. 1, 2014.

15. Elsanti, D. et al. “Hubungan Antara Tingkat Stress dan Aktivitas Fisik terhadap Kejadian Pre Eklampsi pada Ibu Hamil di Wilayah Puskesmas Kalibagor.” Prosiding SNaPP: Kesehatan (Kedokteran, Kebidanan, Keperawatan, Farmasi, Psikologi), vol. 2, no. 1, 2016, pp. 177–186.

16. Khayati, Y.N. and V. Veftisia. “Hubungan Stress dan Pekerjaan dengan Preeklampsia di Wilayah Kabupaten Semarang.” Indonesian Journal of Midwifery (IJM), vol. 1, no. 1, 2018.

17. Setyowati, A. et al. “Development of self-report assessment tool for anxiety among adolescents: Indonesian version of the zung self-rating anxiety scale.” Journal of Public Health in Africa, vol. 10, suppl. 1, 2019.

18. Ananth, C.V. et al. “Pre-eclampsia Rates in the United States, 1980–2010: Age-Period-Cohort Analysis.” BMJ, vol. 347, 2013. https://doi.org/10.1136/bmj.f6564

19. Hutcheon, J.A. et al. “Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 25, no. 4, 2011, pp. 391–403. https://doi.org/10.1016/j.bpobgyn.2011.02.001

20. Poon, L.C. et al. “Combined screening for preeclampsia and small for gestational age at 11–13 weeks.” Fetal Diagnosis and Therapy, vol. 33, no. 1, 2013, pp. 16–27. https://doi.org/10.1159/000341264

21. Lamminpää, R. et al. “Preeclampsia complicated by advanced maternal age: a registry-based study on Primiparous women in Finland 1997–2008.”BMC Pregnancy and Childbirth, vol. 12, no. 1, 2012, pp. 1–5. https://doi.org/10.1186/1471-2393-12-47

22. Kharaghani, R. et al. “Prevalence of preeclampsia and eclampsia in Iran.” Archives of Iranian Medicine, vol. 19, no. 1, 2016, pp. 1–8. https://doi.org/10.1519/AIM.2016.19.1.1

23. Alrubaee, M.A. and L. Kadim. “Feto-maternal outcome of preeclampsia in multigravida compared to primigravida women.”The Medical Journal of Basrah University, vol. 37, no. 2, 2019, pp. 100–105. https://doi.org/10.33762/mjbu.2019.164693

24. Galaviz-Hernandez, C. et al. “Paternal determinants in preeclampsia.” Frontiers in Physiology, vol. 9, 2019, p. 1870. https://doi.org/10.3389/fphys.2018.01870

25. Li, X. et al. “Risk factors for adverse maternal and perinatal outcomes in women with preeclampsia: Analysis of 1396 cases.” The Journal of Clinical Hypertension, vol. 20, no. 6, 2018, pp. 1049–1057. https://doi.org/10.1111/jch.13292

26. Aouache, R. et al. “Oxidative stress in preeclampsia and placental diseases.” International Journal of Molecular Sciences, vol. 19, no. 5, 2018, p. 1496. https://doi.org/10.3390/ijms19051496

27. Chiarello, D.I. et al. “Oxidative stress: Normal pregnancy versus preeclampsia.” Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, vol. 1866, no. 2, 2020, p. 165354. https://doi.org/10.1016/j.bbadis.2019.165354