Iran Journal of Nursing

1. Introduction
Pregnancy is one of the most important stages of a woman’s life, associated with physiological and psychological changes. Still, sometimes pregnancy faces complications that lead to the risk of psychological vulnerability and nervousness. High-risk pregnancies are one of the major problems of midwifery, in which the mother, fetus, and baby are at risk of death. Preeclampsia and hypertension are some of the worst consequences of pregnancy, with the highest frequency of problems. Preterm labor is also one of the high-risk pregnancies due to its higher incidence than other pregnancy complications in Iran. 
Generally, women are concerned about pregnancy and childbirth, the health of the fetus, and accepting the role of the mother. High-risk pregnancies also increase this anxiety. Fetal attachment is closely related to the mother’s emotional conflicts: the mother-child relationship and the relationship with others, which can affect the mother’s mental state. Anxiety and worries jeopardize the mother’s attachment to the fetus and cause maternal complications and fetal health.
There are divergences in studies on the relationship between stress in high-risk pregnancies and maternal-fetal attachment behaviors. This study aimed to determine the relationship between fetal attachment and anxiety and demographic characteristics of nulliparous women with the risk of preeclampsia and preterm labor. 
2. Methods
The present study was a cross-sectional descriptive study. Two hundred pregnant women who had preeclampsia, hypertension, and preterm were selected in the two prenatal clinics of Iran University Medical Sciences, which had the most referrals. This study was carried out from 2018 to 2019. The Sample method was simple random. First, according to the daily referral statistics of 8 to 10 women with high-risk pregnancies in the three mentioned complications, the researcher prepared a list of their names on the same day. Using the table of random numbers were selected 4-5 characters. The researcher introduced herself to women. Then, they clarified the purpose of the study, obtained their consent, and completed the consent form. 
Inclusion criteria included Iranian nationality, ability to read and write, gestational age between 28 and 40 weeks, and no mental illness as a self-report or medical record. The questionnaire included a demographic and midwifery form: Cranley fetal attachment and a Wendenberg pregnancy anxiety questionnaire. Sampling started in July 2018 and ended in June 2019 from Saturday to Wednesday. Data were analyzed by SPSS software v. 16 using an independent t-test, analysis variance (ANOVA), Pearson correlation coefficient, and logistic regression.
3. Results
The Mean±SD of fetal attachment was 55.26±12.68, which was reported as moderate. The Mean±SD of women’s anxiety was 196.20±34.66, which was higher than the median of the scale. There was a statistically significant correlation between the total score of fetal attachment and the total score of female anxiety (P<0.001). With increasing fetal attachment, anxiety also increased in high-risk pregnant women. The Mean±SD age of women was 31.76±3.92 years, and the Mean±SD gestational age was 34.22±2.48. The Mean±SD number of years of education for women was 14.68±2.55, more than half of women reported 12 and 16 for their education years, and their husbands were also 15.65±2.12. About 84.5% of women had a planned pregnancy. 62% of women received relatively good social support from their husbands. 
Higher education for mother and father, more support of the spouse to the pregnant mother, and planning for pregnancy in the current pregnancy were significantly and inversely related to maternal attachment to the fetus and maternal anxiety during pregnancy. That means the higher the parents’ education, the less attachment to the fetus and the less anxiety, and the more support the spouses during pregnancy, the less anxiety, and attachment to the fetus. Mothers with unplanned pregnancies also had more anxiety and reported more attachment to the fetus despite being at high risk (P<0.001).
4. Conclusion
There was a correlation between fetal attachment and anxiety in high-risk pregnant mothers. Pregnant mothers’ education, spouses’ education, spouse’s support of the pregnant mother, and planning to become pregnant were inversely related to fetal attachment. Maternal anxiety was also inversely associated with the personal characteristics mentioned above. In other words, less education for pregnant mothers and lack of planning to become pregnant had caused them to become more attached to the fetus. These mothers had expressed more concern in the face of pregnancy complications and preeclampsia, hypertension, and preterm labor. It seems that the efforts of staff and health care providers should be towards pregnancy care in this group of women with higher quality and more consultation time. To increase mothers’ knowledge when special problems occur and timely referral of the mothers. Obeying the necessary treatment. To follow-up on pregnancy. Ensuring safe pregnancy and delivery and a healthy baby will also guarantee women’s mental health. It should be a good step in the positive experience of childbearing and natural childbirth. 

Ethical Considerations
Compliance with ethical guidelines
Ethical code was obtained from the University Ethics Committee Iranian Medical Sciences (IR.IUMS.REC 1396.4540001779).

Funding
This article has no sponsorship and is taken from a senior midwifery thesis.

Authors' contributions
Conceptualization, Supervision, Methodology: Mansoureh Jamshidi Manesh; Research, writing, original draft, writing, review and editing: Mansoureh Jamshidi and Parisa Cheraghi. Data collection: Parisa Cheraghi; Data Analysis: Shima Haqqani.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
This article was the result of a master's thesis in midwifery and the authors express their gratitude to the prenatal ward of Shahid Akbarabadi and Firoozgar hospitals of Iran University of Medical Sciences and the School of Nursing and Midwifery of Iran University of Medical Sciences.


References

1. Dennis-Tiwary TA, Denefrio S, Gelber S. Salutary effects of an attention bias modification mobile application on biobehavioral measures of stress and anxiety during pregnancy. Biol Psychol. 2017; 127:148-56. [DOI:10.1016/j.biopsycho.2017.05.003] [PMID] [PMCID]
2. Massey SH, Bublitz MH, Magee SR, Salisbury A, Niaura RS, Wakschlag LS, et al. Maternal-fetal attachment differentiates patterns of prenatal smoking and exposure. Addict Behav. 2015; 45:51-6. [DOI:10.1016/j.addbeh.2015.01.028] [PMID] [PMCID]
3. Cranley MS. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res. 1981; 30(5):281-4. [DOI:10.1097/00006199-198109000-00008] [PMID]
4. Campion B. Maternal-fetal attachment and the culture of life one: An examination of maternal fetal attachment. Bioeth Matters Enj Bioeth. 2013; 12(2):1-4. https://www.sid.ir/en/Journal/ViewPaper.aspx?ID=453397
5. Gürol A, Polat S. The effects of baby massage on attachment between mother and their infants. Asian Nurs Res. 2012; 6(1):35-41. [DOI:10.1016/j.anr.2012.02.006] [PMID]
6. Machado MdSR, Bertagnolli TV, Veiga ECdA, Ferreira CJH, Duarte G, Machado JdSR, et al. Multiprofessional care promotes of quality of life in pregnant women with preeclampsia: A cross-sectional study. Clinics. 2020; 75:e1951. [DOI:10.6061/clinics/2020/e1951] [PMID] [PMCID]
7. Loughnan SA, Wallace M, Joubert AE, Haskelberg H, Andrews G, Newby JM. A systematic review of psychological treatments for clinical anxiety during the perinatal period. Arch Women’s Mentl Health. 2018; 21(5):481-90. [DOI:10.1007/s00737-018-0812-7] [PMID]
8. Bazrafshan S, Kheirkhah M, Inanlou M, Rasouli M. Controlling the anxiety in Iranian pregnant women at risk of preterm labor by undergoing the counseling group intervention. J Fam Med Prim Care. 2020; 9(8):4016-25. [DOI:10.4103/jfmpc.jfmpc_1227_19] [PMID] [PMCID]
9. Costa-Martins JM, Pereira M, Martins H, Moura-Ramos M, Coelho R, Tavares J. Retracted: Attachment styles, pain, and the consumption of analgesics during labor: A prospective observational study. J Pain; 2014; 15(3):304-11. [DOI:10.1016/j.jpain.2013.12.004] [PMID]
10. Pallant JF, Haines HM, Hildingsson I, Cross M, Rubertsson C. Psychometric evaluation and refinement of the prenatal attachment inventory. J Reprod Infant Psychol. 2014; 32(2):112-25. [DOI:10.1080/02646838.2013.871627]
11. Isaacs NZ, Andipatin MG. A systematic review regarding women’s emotional and psychological experiences of high-risk pregnancies. BMC Psychol. 2020; 8:45. [DOI:10.1186/s40359-020-00410-8] [PMID] [PMCID]
12. Belay AS, Wudad T. Prevalence and associated factors of pre-eclampsia among pregnant women attending anti-natal care at Mettu Karl referal hospital, Ethiopia: Cross-sectional study. Clin Hypertens. 2019; 25:14. [DOI:10.1186/s40885-019-0120-1] [PMID] [PMCID]
13. Qin LL, Lu FG, Yang SH, Xu HL, Luo BA. Does maternal vitamin D deficiency increase the risk of preterm birth: A meta-analysis of observational studies. Nutrients. 2016; 8(5):301. [DOI:10.3390/nu8050301] [PMID] [PMCID]
14. Halimi Asl AA, Safari S, Parvareshi Hamrah M. Epidemiology and related risk factors of preterm labor as an obstetrics emergency. Emer. 2017; 5(1):e3. [PMID] [PMCID]
15. Kordi M, Vahed A, Rezaee Talab F, Mazloum SR, Lotfalizadeh M. Anxiety during pregnancy and preeclampsia: A case-control study. J Midwifery Reprod Health. 2017; 5(1):814-20. [DOI:10.22038/jmrh.2016.7881]
16. Allahem H, Sampalli S. Framework to monitor pregnant women with a high risk of premature labour using sensor networks. 2017 IFIP/IEEE Symposium on Integrated Network and Service Management (IM); 2017: IEEE. [DOI:10.23919/INM.2017.7987458]
17. Tavakolipour S, Beigi M, Nekuei N, Shafiei F. The prevalence of pregnancy hypertensive disorders and their related factors in the second and third level hospitals affiliated to Isfahan university of medical Sciences, Isfahan, Iran. J Midwifery Reprod Health. 2019; 7(3):1726-31. [DOI:10.22038/jmrh.2019.32423.1353]
18. Amini P, Maroufizadeh S, Samani RO, Hamidi O, Sepidarkish M. Prevalence and determinants of preterm birth in Tehran, Iran: A comparison between logistic regression and decision tree methods. Osong Public Health Res Perspect. 2017; 8(3):195-200. [DOI:10.24171/j.phrp.2017.8.3.06] [PMID] [PMCID]
19. Dagklis T, Tsakiridis I, Chouliara F, Mamopoulos A, Rousso D, Athanasiadis A, et al. Antenatal depression among women hospitalized due to threatened preterm labor in a high-risk pregnancy unit in Greece. J Matern Fetal Neonatal Med. 2018; 31(7):919-25. [DOI:10.1080/14767058.2017.1301926] [PMID]
20. Karimi-Zarchi M, Schwartz DA, Bahrami R, Dastgheib SA, Javaheri A, Tabatabaiee RS, et al. A meta-analysis for the risk and prevalence of preeclampsia among pregnant women with COVID-19. Turk J Obstet Gynecol. 2021; 18(3):224-35. [DOI:10.4274/tjod.galenos.2021.66750] [PMID] [PMCID]
21. Kucharska M. Selected predictors of maternal-fetal attachment in pregnancies with congenital disorders, other complications, and in healthy pregnancies. Health Psychol Rep. 2020; 9(3)193-206. [DOI:10.5114/hpr.2020.97295]
22. Lee SA, Lee SH. Factors influencing maternal-fetal attachment among pregnant women. J Korea Acad-Ind Coop Soc. 2015; 16(3):2020-8. [DOI:10.5762/KAIS.2015.16.3.2020]
23. Javanmardi M, Noroozi M, Mostafavi F, Ashrafi-Rizi H. Challenges to access health information during pregnancy in Iran: A qualitative study from the perspective of pregnant women, midwives and obstetricians. Reprod Health. 2019; 16(1):128. [DOI:10.1186/s12978-019-0789-3] [PMID] [PMCID]
24. Rollè L, Giordano M, Santoniccolo F, Trombetta T. Prenatal attachment and perinatal depression: A systematic review. Int J Environ Res Public Health. 2020; 17(8):2644. [DOI:10.3390/ijerph17082644] [PMID] [PMCID]
25. Baba Nazari L, Kafi SM. [Relationship of pregnancy anxiety to its different periods, sexual satisfaction and demographic factors (Persian)]. Iran J Psychiatry Clinl Psychol. 2008; 14(2(53)):206-13. http://ijpcp.iums.ac.ir/article-1-473-en.html
26. Cunha Ad, Akerman L, Rocha A, Rezende KdC, Junior J, Bornia R. Stress and anxiety in pregnant women from a screening program for maternal-fetal risks. J Gynecol Obstet. 2017; 1:013. http://lepids.org/inicio/sites/default/files/2019-04/Stress_and_Anxiety_in_Pregnant_Women_fro.pdf
27. Bowlby J. Attachment and loss: Retrospect and prospect. Am J Orthopsychiatry. 1982; 52(4):664. [DOI:10.1111/j.1939-0025.1982.tb01456.x] [PMID]
28. Özkahraman-Koç Ş, Ersoy S, Yıldırım B, Ersoy İH. Anxiety, depression, and prenatal attachment levels in pregnant women with gestational diabetes mellitus. Int J Clin Exp Med. 2019; 12(5):6078-86. https://avesis.sdu.edu.tr/yayin/7e0fbcef-a024-4898-b372-7725f57873f0/anxiety-depression-and-prenatal-attachment-levels-in-pregnant-women-with-gestational-diabetes-mellitus
29. Pakseresht S, Rasekh P, Leili EK. physical health and maternal-fetal attachment among women: Planned versus unplanned pregnancy. Int J Womens Health Reprod Sci. 2018; 6(3):335-41. [DOI:10.15296/ijwhr.2018.55]
30. Bülbül M, Dilbaz B, Koyuncu SB, Yağmur Y. Is Increased stress affecting prenatal attachment in high risk pregnancies? J Med Pract Rev. 2018; 2(08). http://jmpr.info/index.php/jmpr/article/view/78
31. Adair LE. Fertility decision making: To what extent do adaptations, social pressures, and individual differences influence plans to have a child? [MSc. Thesis]. Kansas: Kansas State University; 2013. http://hdl.handle.net/2097/15700
32. Söderberg M, Christensson K, Lundgren I. A project for future life-Swedish women’s thoughts on childbearing lacking experience of giving birth and parenthood. Int J Qual Stud Health Well-being. 2012; 7(1):17318. [DOI:10.3402/qhw.v7i0.17318] [PMID] [PMCID]
33. Hassan NMM, Hassan F. Predictors of maternal fetal attachment among pregnant women. IOSR J Nurs Heal Sci. 2017; 6(1):95-106. [DOI:10.9790/1959-06010695106]
34. Mercer RT, Ferketich S, May K, DeJoseph J, Sollid D. Further exploration of maternal and paternal fetal attachment. Res Nurs Health. 1988; 11(2):83-95. [DOI:10.1002/nur.4770110204] [PMID]
35. Jenabi E, Khazaei S, Bashirian S, Aghababaei S, Matinnia N. Reasons for elective cesarean section on maternal request: A systematic review. J Matern Fetal Neonatal Med. 2019:1-6. [DOI:10.1080/14767058.2019.1587407] [PMID]