1.       Findings

• In our study, we also found that pregnant women with lower levels of education were at a higher risk for developing anxiety during pregnancy.
• Some other studies have also found this association between poor education and mental health
• The only demographic characteristic significantly associated with antenatal anxiety was lack of tertiary education
• Among the sociodemographic factors, we could not demonstrate any relevant association of pregnancy-related anxiety with age, respondent’s education and occupation; and husband’s education
• The burden of anxiety was seemingly higher among women who belonged to lower socioeconomic classes;
• Moreover, our study shows that pregnancy-induced hypertension syndrome and anemia during pregnancy are the major risk factors of antenatal anxiety among pregnant women
• Besides, this study has revealed that anxiety during pregnancy is associated with natural delivery method. To our surprise, our study found that planned cesarean deliveries, including those requested by the mother without medical reasons, were more common than planned natural deliveries (283 vs. 184)..
• Among the psychosocial factors, low social support emerged as a significant predictor of anxiety
• Compared with any demographic characteristic, first trimester EPDS scores showed the strongest association with high state anxiety
• Our study finds a statistically significant relation between disharmony in family relationship and anxiety
• We could not find any important linkage between anxiety and obstetric history, although many studies show higher levels of anxiety among primiparous women.37,38 Also, an unplanned pregnancy or a history of medical complaint did not appear to predispose to prenatal anxiety
• Besides, this study has revealed that anxiety during pregnancy is associated with natural delivery method
• Moreover, our study shows that pregnancy-induced hypertension syndrome and anemia during pregnancy are the major risk factors of antenatal anxiety among pregnant women

2.       Relationship to other studies

a.       The relationship reported here between previous live term births and lower pregnancy anxiety corroborates results reported by Saisto and colleagues

b.       In regard to the relationship of anxiety with a woman’s education, different studies report conflictive findings. While Lau and Yin²⁸ (2011) contended that well educated women could handle stress in a better way during pregnancy;28 other authors claim that the stress levels could be much higher in this group.29,30

c.       which is in concurrence with other study results.31–34 However, Kingston et al35 (2012) and Renae Stancil et al36(2000), found lower levels of stress in lower income group women.

d.       However, to our knowledge, the literature on antenatal anxiety with pregnancy complication is limited. A previous research had shown that pregnant women in hospitals tended to become more anxious and vulnerable when they were in poor health [23], which is consistent with our study. Also, in another study, pregnant women with preeclampsia reported complete shock and tended to suffer from high anxiety due to fear of babies’ prematurity, loss and guilt [43]. Therefore, pregnant women with complications should be given more psychological care from caregivers and their families, which could diminish the occurrence and development of antenatal anxiety.

• Some other studies have also found this association between poor education and mental health 

3.       Reasons for findings

a.       A lower level of education is correlated with a lower socioeconomic status, and individuals with these qualities lack adequate resources and information to improve their situation during pregnancy

b.       Higher education is linked with higher employment rates and income, and highly educated people tend to enjoy better health and are more likely than their counterparts to seek medical treatment early when ill.32,33 Given the high value placed on education and achievement in Singapore, and that nearly two-thirds of our participants had a tertiary education, it is probable that the less educated minority lacked advantages and means that may have protected against anxiety

c.       The fear of giving birth and experiencing a natural delivery is a real challenge for women, and this fear is strongly linked to the request for a cesarean section. Pang et al. found that women voluntarily elected cesarean sections after having their first child, even when they had attempted to give birth naturally in the past [37]. There are many unknown factors during pregnancy that cannot be controlled and that sometimes result in emergency cesarean deliveries, including situations involving intrauterine growth restriction, which eventually threatens the mother’s or the baby’s life. In addition, pregnant women are conscious during natural childbirth, are without the use of analgesics or anesthetics, and experience labor pain for at least a few hours. We suggest that these worries and fears contribute to the escalating prevalence of antenatal anxiety. According to Maier, for pregnant women, a planned cesarean section is a well-tolerated procedure, psychologically, when compared to natural childbirth [44]. Thus, as psychophysical care is an integral part of childbirth, professionals and caregivers need to pay close attention to women’s psychological status in the management of pregnancy and labor pain