An earthquake is a natural disaster that creates many problems. Thousands of people lost their lives after the devastating earthquakes that occurred in Turkey on February 6, 2023. The earthquakes negatively affected at least 15 million people in Turkey, which led to the declaration of a national emergency and a call for international support.1 While the short-term effects of disasters such as earthquakes are associated with physical trauma, negative environmental impacts, and irregular sheltering, long-term effects could include displacement, changes in family relationships, and negative economic consequences. Particularly vulnerable groups such as children, pregnant women, individuals with chronic diseases, and the elderly are affected more. According to the Association of Maternal-Fetal Medicine and Perinatology of Turkey, natural disasters cause negative effects on women during and after pregnancy as well as on children, and taking necessary measures is important.Reference Villasana2–Reference Çelen, Yanık and Mendilcioğlu4 Individuals who experience earthquakes are reported to also experience negative behavioral changes, such as difficulty in accessing health services, increased stress, negative effects on mental health, smoking and substance use, and malnutrition.Reference Villasana2, Reference Harville, Beitsch and Uejio3
Pregnant women who experience an earthquake are also reported to experience negative effects due to spontaneous abortion, the threat of preterm birth, late delivery, increases in cesarean deliveries, insufficient weight gain during pregnancy, decreased hemoglobin levels, and decreased breastfeeding.Reference Esfandyari, Vaghef-Mehrabany and Ebrahimi-Mameghani5–Reference Tan, Li and Zhang9 Earthquakes also significantly affect pregnant women’s cognitive processes and behaviors. These effects may vary from individual to individual.Reference Yöndem and Eren10
Stress is a condition that negatively affects individuals’ normal functions and quality of life, and it could lead to various health problems when exposure lasts for a long time. The literature has documented a strong relationship between stress and mental health.Reference Eskin, Harlak and Demirkıran11, Reference Çevik and Şentürk12 Pregnant women’s mental health is one of the basic components of maternal health. Fear and anxiety caused by the earthquake affect mental health negatively during pregnancy.Reference Villasana2 The literature has identified factors causing concerns in pregnancy during and after natural disasters, which are listed as birth; infant and newborn health and care; family and parenting; sheltering and finance; breastfeeding; immigration; mental health problems; death; and loss.Reference Giarratano, Barcelona and Savage13
Individuals exposed to stressful situations resort to various coping strategies to avoid the negative emotions caused by stress.Reference Yöndem and Eren10 Providing pregnant women, who are among the vulnerable groups, with mental health support services is very important to help them cope with the psychological trauma caused by earthquakes.Reference Villasana2 These support services may include reproductive health support and psychological counseling services for pregnant women and the development of monitoring and early health interventions for newborns.Reference Guo14 Strengthening social support for pregnant women is reported to develop positive coping behaviors.Reference Ren, Jiang and Yao15 In addition, emotion-focused coping strategies may be useful in the face of uncontrollable events such as earthquakes. In this regard, some positive behaviors and attitudes asking for emotional support from others, and trying to see the positive aspects of the situation are recommended.Reference Chen, Laplante and Elgbeili16 The literature highlights the importance of determining the factors to affect the level of stress perceived by pregnant women, developing appropriate individual coping skills, and establishing extended support networks based on social and health policies after natural disasters such as earthquakes. An analysis of the literature on the issue indicates that there are studies that investigated the effects of earthquakes on mental health during pregnancyReference Giarratano, Barcelona and Savage13, Reference Khatri, Tran and Fisher17–Reference Futterman, Grace and Weingarten19 and its relationship with coping strategies.Reference Ren, Jiang and Yao15, Reference Chen, Laplante and Elgbeili16 However, no studies were found to have investigated the perceived stress levels and coping styles of pregnant women who experienced an earthquake in tandem. Hence, the purpose of this study is to determine the factors associated with perceived stress and coping styles of pregnant women after the devastating earthquake in Turkey.
Methods
Research Design and Research Questions
This cross-sectional and descriptive study sought answers to the following research questions;
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- What are the factors predicting perceived stress levels after the earthquake?
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- What are the factors predicting coping styles with earthquake stress?
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- Is there a relationship between perceived stress levels and coping styles after the earthquake?
Setting and time of the study
The target population of the study consisted of pregnant women who sought treatment in a public hospital between March 15 and May 15, 2023. The sample size of the study was calculated using the sampling method with a known population. A total of 2900 pregnant women were admitted to the relevant hospital in 1 month. Considering that a similar number of pregnant women would come to the related hospital monthly, it was determined that the study should be conducted with a minimum of 340 pregnant women (https://www.calculator.net/samplesizecalculator.html?type=1&cl=95&ci=5&pp=50&ps=2900&x=62&y=22). Considering the possible losses, the sample size was increased by approximately 20%, and the study was completed with the participation of 419 pregnant women. The study included pregnant women who agreed to participate in the study, who were open to cooperation and communication, who understood and spoke Turkish, who were in any trimester of pregnancy, and who had experienced the earthquake on February 6th. Women diagnosed with high-risk pregnancy were excluded from the study.
Data collection
Data were collected through the “Personal Information Form,” the “Perceived Stress Scale,” and the “Coping with Earthquake Stress Scale.” Data collection was performed by meeting the participants face-to-face, which took about 10-12 minutes. At the beginning of the data collection process, pregnant women were informed about the study, and their written informed consent was obtained.
Personal information form. The form developed by the researchers in line with the literature consists of a total of 16 questions including questions about pregnant women’s socio-demographic, obstetric, and earthquake-related characteristics.Reference Futterman, Grace and Weingarten19, Reference Nomura, Rompala and Pritchett20
Perceived Stress Scale (PSS). The Perceived Stress Scale was developed by Cohen et al. (1983).Reference Cohen, Kamarck and Mermelstein21 Turkish adaptation of the scale was performed by Eskin et al. (2013). The 5-point Likert-type scale consists of 14 items that measure the extent to which a person subjectively perceives certain situations as stressful. Seven of the scale items (4,5,6,7,7,9,10,13) are scored reversely. The total score obtained from the scale ranges from 0-56, with higher scores indicating higher perceived stress. The internal consistency coefficient of the Turkish scale was found to be 0.84.Reference Eskin, Harlak and Demirkıran11 In this study, Cronbach’s alpha internal consistency coefficient was determined as 0.76.
Coping with Earthquake Stress Scale (CESS). The scale was developed by Yöndem and Eren (2008). The 4-point Likert-type scale (1 = Never- 4 = Always) consists of 16 questions and 3 sub-scales that include Religious Coping (items 1,2,3,4, and 5), Positive Reappraisal (items 6, 7, 8, 9, 10 and 11), and Seeking Social Support (items 12, 13, 14, 15, and 16). The scores to be obtained from the scale range from 16-64. Items 14 and 15 are scored reversely in the Seeking Social Support sub-scale. Higher scores obtained for all sub-scales indicate higher levels of use of a specific coping strategy. Cronbach’s alpha internal consistency coefficients were 0.85 for Religious Coping, 0.69 for Positive Reappraisal, and 0.74 for Seeking Social Support.Reference Yöndem and Eren10 In this study, Cronbach’s alpha values were found to be 0.96 for Religious Coping, 0.83 for Positive Reappraisal, and 0.70 for Seeking Social Support.
Data analysis
Data were analyzed using the IBM SPSS Statistics Standard Concurrent User V 26 (IBM Corp., Armonk, New York, USA) statistical package program. Descriptive statistics were given as number of units (n), percentages (%), means (Mean), standard deviations (SD), medians (M), and minimum (min) and maximum (max) values. The normality distribution of the numerical variables was analyzed by the Shapiro-Wilk normality test. While student’s t test was used to compare 2 groups, One-Way ANOVA was used to compare more than 2 groups. Multiple comparisons were made using the Bonferroni test. Multivariate regression analysis was used to determine the factors predicting perceived stress and coping style. The relationships between numerical variables were analyzed using the Pearson correlation coefficient. Statistical significance was accepted as ≤0.05 in the analyses.
Ethical approval
Approval to conduct the study was obtained from the Non-Interventional Clinical Research Ethics Committee of the Faculty of Medicine (03.10.2023/Meeting:131/Decision:22) at Çukurova University. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Results
Table 1 demonstrates the participants’ sociodemographic, obstetric, and depression-related characteristics. A statistically significant difference was found between the pregnant women’s PSS total mean scores and variables such as income level, education level, employment status, trimester of pregnancy, number of pregnancies, planning pregnancy, previous experience of natural disasters, regular follow-up visits after the earthquake, and damage to the house in this earthquake (P < 0.05) (Table 1).
Sociodemographic, obstetric, and earthquake variable characteristics of the participants and mean scale scores (N = 419)
* P < 0.05; Student’s t test (z); One-Way ANOVA (F); Introductory statistics Mean (X) ± Standard Deviation(SD) are given as values.
A significant difference was found between the CESS total score and variables such as pregnant women’s age, ıncome level, education level, employment status number of pregnancies damage to their house, previous experience of a natural disaster, and losing a relative in the last earthquake (P < 0.05) (Table 1).
Multiple regression was used to test the prediction of perceived stress based on age, ıncome, education, employment status, place of residence, trimester, pregnancy planning status, regular follow-up visits after the earthquake, and damage to the house in the last earthquake. A significant regression equation was found with an R 2 value of 0.109 (F = 4.118, P < 0.001). Employment status (β = -2.009, P = 0.045) and number of pregnancies (β = -2.934, P = 0.004) were found to significantly predict perceived stress (Table 2).
Regression analysis of factors effective on PSS
* P < 0.05; β: Regression Coefficient. se: Standard error. zβ: Standardized regression coefficient. R 2: Coefficient of determination.
Multiple regression was used to test the prediction of coping style based on age, ıncome, education, employment status, place of residence, trimester, pregnancy planning status, regular follow-up visits after the earthquake, and damage to the house in the last earthquake. A significant regression equation was found with an R 2 value of 0.264 (F = 12.112, P < 0.001). Age (β = -1.977, P = 0.049), income status (β = -2.983, P = 0.003), place of residence (β = -2.109, P = 0.036), and employment status (β = 3.240, P < 0.001) were found to significantly predict coping style (Table 3).
Regression analysis of factors effective on CESS
* P < 0.05; β: Regression Coefficient. se: Standard error. zβ: Standardized regression coefficient. R 2: Coefficient of determination.
As seen in Table 4, the effect of CESS scores on PSS scores was analyzed using multivariate regression analysis. The model for PSS was statistically significant and met the assumptions of multivariate regression analysis (F = 3.638; P = 0.013). The findings showed that religious beliefs and coping strategies had a significant and negative effect on perceived stress (β = -0.260, P = 0.002). The overall explanatory power of the model was found to be 2.6% (Table 4).
Regression analysis of the effects of CESS subscale scores on PSS (N=419)
* P < 0.05; β: Regression Coefficient. se: Standard error. zβ: Standardized regression coefficient. R 2: Coefficient of determination.
An analysis of scale correlations indicated a negative and linear relationship between the PSS total mean score and the “Religious Coping” (P = 0.006, r = -0.134), “Positive Reappraisal” (P = 0.031, r = -0.106), and the CESS total mean score (P = 0.005, r = -0.135). No statistically significant correlation was found between the PSS total mean score and the “Social Support” sub-scale mean score (P > 0.05, r = -0.008) (Table 5).
Correlation between PSS with CESS total and sub-scale (N=419)
* P < 0.05; r: Pearson correlation coefficient.
Discussion
This study aimed to determine predictive factors associated with pregnant women’s perceived stress and coping styles after the devastating earthquake in Turkey and answered the research questions. While the literature includes studies that investigated the psychological problems, depression, and Posttraumatic Stress Disorder (PTSD) of pregnant women after the earthquake,Reference Ren, Jiang and Yao15, Reference Qu, Tian, Zhang and Wang18, Reference Kyozuka, Murata and Yasuda22, Reference Watanabe, Iwama and Nishigori23 only 1 studyReference Cohen, Kamarck and Mermelstein21 was found to have investigated the factors affecting the perceived stress of pregnant women after the earthquake. Existing studies report that pregnant women are more likely to experience psychological problems after an earthquake.Reference Ren, Jiang and Yao15, Reference Qu, Tian, Zhang and Wang18, Reference Cohen, Kamarck and Mermelstein21–Reference Watanabe, Iwama and Nishigori23 Generally, floods and hurricanes could occur simultaneously with earthquakes.Reference Glynn, Wadhwa and Dunkel-Schetter24 Such a condition leads to a lack of access to a quality diet during pregnancy, pregnancy complications, and increased maternal stress.Reference Ha25 In addition to these situations, due to the disruption of regular pregnancy follow-ups after the earthquake, women do not have enough information about themselves and their fetuses, which may lead to an increase in the stress perceived by them. This study found that the variables of employment status and number of pregnancies affected the perceived stress. The results of this study showed that the perceived stress was higher in pregnant women who worked after the earthquake. The literature was found to include no studies that reported the effect of the employment status variable on pregnant women’s perceived stress after the earthquake. However, a study that investigated the relationship between working pregnant women’s workload and pregnancy outcomes reported that increased physical activity and workload during work increased pregnant women’s stress levels.Reference Reda, Rasha and Ashraf26 In addition, uncertainties, safety concerns, and environmental factors after earthquakes may increase working pregnant women’s stress. The presence of workload in this period may make stress management difficult. This study found that perceived stress was higher in women who had their first pregnancy. A study conducted by Dilcen et al. (2024) reported that the reason for the high level of stress perceived by women experiencing their first pregnancy may be related to the fact that major life events, such as disasters, make this process more difficult.Reference Yalniz Dilcen, Çakır Koçak and Ada27 Studies in the literature show that due to uncertainties and inexperience, women who are experiencing their first pregnancy may be more sensitive to stress factors in disaster situations.Reference Yalniz Dilcen, Çakır Koçak and Ada27, Reference Howells, Wander and Rivera28 Contrary to our study findings, Qu et al. (2012) found an increase in PTSD levels in women who had 2 or more pregnancies after the earthquake.Reference Qu, Tian, Zhang and Wang18 Pregnancy is experienced for the first time in primiparous pregnancies, which increases uncertainties. In this study, in addition to the uncertainty caused by the pregnancy, the experience of an earthquake disaster may be an effective factor in increasing stress levels. This study found that age, income level, employment status, and place of residence variables affected coping skills with an earthquake. The present study found that pregnant women used coping strategies more as their age and ıncome level decreased. The literature includes no studies that investigated the relationship between the age factor and coping strategies after the earthquake. The fact that young pregnant women use coping strategies more may be associated with their lower life burden. Studies have reported that destruction and deaths after the earthquake cause economic problems and disruptions in education.Reference Ren, Jiang and Yao15, Reference Watanabe, Iwama and Nishigori23 Economic difficulties may increase the tendency to use coping strategies. Unemployed pregnant women in this study were found to use coping strategies more often after earthquakes. The literature includes limited studies on the working status of pregnant women. In their study conducted after the Ya’an Lushan Earthquake in China, Ren et al. (2015) found that employment status increased positive coping styles and reduced prenatal depression in pregnant women.Reference Ren, Jiang and Yao15 Akça et al. (2024) investigated coping styles with the same scale in adult individuals after the earthquake in Turkey and found that working individuals preferred the positive reappraisal strategy more.Reference Akca, Bilgehan and Karşıgil29 In the present study, unemployed pregnant women may have more physical and mental free time, which may lead them to develop more strategies to cope with the stress they experience. These pregnant women may have the potential to make individual efforts. Different results might be caused by the fact that the sample group consisted of pregnant individuals from different cultures. This study found that pregnant women living in the city used coping strategies more. No specific articles were found to compare the coping strategies of pregnant women living in urban or rural areas. The results of this study showed that the pregnant women living in the city used more coping strategies, which may be related to both access to modern facilities and higher levels of awareness. However, it is also important to support women living in rural areas in this regard. In particular, strengthening access to health services, education programs, and social support mechanisms can increase the coping skills of pregnant women in rural areas. In natural disasters, people feel lonely and look for a way out. Using at least 1 coping strategy may help people search for answers as to why this disaster happened to them, feel relieved by thinking that they have been tested, feel that they are not alone through support from their environment, and increase their belief in coping with earthquake stress. In our study, when the effect of CESS scores on PSS scores was analyzed by multivariate regression analysis, it was found that the religious coping sub-scale was a predictive factor on perceived stress. In other words, pregnant women were found to use religious coping strategies more as their stress decreased. Disasters that cause physical and psychological changes, such as earthquakes, make pregnant women especially vulnerable.Reference Harville, Beitsch and Uejio3, Reference Guo14 Post-traumatic stress disorder, depression, increased suicide rates, premature births, and negative psychopathologies in pregnancy after the earthquake may have negative consequences on maternal and child health.Reference Guo14 Negative factors caused by depression may increase the perceived stress levels of pregnant women and may cause them not to use coping skills adequately. The results of this study show that pregnant women who can manage their stress can use religious coping more. Religion has always existed throughout the history of humanity. The feeling of relying on and taking refuge in the Creator gives people a sense of confidence and comfort. Therefore, in every negative situation, such as disasters, people seek refuge in the Creator and feel comforted with a sense of trust.Reference Gören30, Reference Güler31 In all societies, the increase in religious tendencies in natural disasters reflects the effect of the characteristics of the social structure. It could be concluded that the reflection of religious rituals on coping strategies may be an expected situation in traditional Turkish society. An analysis of the scale correlations indicated a negative and linear relationship between perceived stress and religious coping, positive reappraisal, and the total mean score for coping with earthquake stress. In other words, as their perceived stress decreased, pregnant women used coping skills in general, especially religious coping and positive reappraisal skills. Mesidor and Sly (2019) reported that positive religious coping was the strongest predictor of post-traumatic stress disorder.Reference Mesidor and Sly32 High perceived stress may deplete individuals’ cognitive resources, making it more difficult for them to employ effective coping strategies, which in turn may lead to a reduced use or effectiveness of religious coping, positive reappraisal, and coping with earthquake stress. Chen et al. (2020) reported that pregnant women used emotion-focused coping strategies more to reduce their subjective distress after natural disasters.Reference Chen, Laplante and Elgbeili16 Akça et al. (2024) reported that religious coping was the most preferred method among individuals staying in tent cities after the earthquake.Reference Akca, Bilgehan and Karşıgil29
Conclusions and Recommendations
This study analyzed the stress perceived by pregnant women after the devastating earthquake in Turkey and the factors affecting their coping strategies. It was found that various factors affected the stress perceived by pregnant women after the earthquake and their coping strategies. The variables of employment status and number of pregnancies affected perceived stress, age, income status, place of residence, and employment status, which were found to affect coping skills with earthquake stress. Pregnant women were found to use coping skills as their perceived stress decreased, and they used especially religious coping and positive reappraisal strategies more.
The psychological well-being of women during pregnancy plays an important role in the development of society by affecting both the mother and the baby. Natural disasters like earthquakes could negatively affect physical and mental health by exposing individuals to excessive stress. Determining pregnant women’s physical and psychological needs and coping strategies after earthquakes is crucial for minimizing or even eliminating the negative effects of earthquakes on women’s health in the short and long term. In light of these findings, providing health services regularly after earthquakes is of great importance to reduce pregnant women’s stress levels and support their psychological health. Guidance, social support, and awareness-raising programs should be developed for the stress perceived by especially primiparous and vulnerable pregnant women living in rural areas. Given that coping strategies have an important place in the structure of society, it is recommended to plan supportive interventions in accordance with cultural characteristics that consider individual characteristics. Furthermore, midwives and nurses guiding pregnant women in managing their stress by using their counseling skills in post-disaster periods may also support pregnant women in using their coping skills.
Strengths and Limitations
This study has some strengths and limitations. The most important strength is that it is a pioneering study contributing to the limited number of studies that have evaluated the stress perceived by pregnant women after earthquakes and the factors affecting their coping skills.
As for the limitations, because this study constitutes a sample including only pregnant women admitted to the hospital, the results cannot be generalized to the general population. Data in this study were based on pregnant women’s self-reports, which may not reflect their actual coping skills. In addition, due to the limitations of the cross-sectional design, no precise causal relationships can be explained.
Acknowledgements
We would like to thank all the participants.
Author contribution
Aslıhan Turan: Conceptualization, Methodology, Formal analysis, Writing – review & editing. Esra Biçer: Conceptualization, Methodology, Writing – review & editing. Rukiye Sulu Dursun: Conceptualization, Methodology, Writing – review & editing. Ebru Gözüyeşil: Investigation, Writing – original draft, Visualization.
Funding statement
This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
