Psychological challenges and adaptations during high-risk pregnancy- A narrative review and practice insight

Prevalence and contributing factors of high-risk pregnancy

High-risk pregnancies affect nearly 20 million women globally, accounting for approximately 6% to 33% of all pregnancies, and are responsible for over 800 maternal deaths each day, 99% of which occur in low- and middle-income countries.² According to the Sample Registration System, India has seen a decline in its maternal mortality ratio (MMR), dropping from 113 per 100,000 live births (2016-2018) to 103 per 100,000 (2017-2019).^3,4

Multiple factors contribute to high-risk pregnancies. Maternal risk factors include early adolescence (ages 15-17), advanced maternal age (over 35), shorter stature (under 140 cm), and elevated BMI (≥30 kg/m² or ≥25 kg/m² for obese Asian Indian women), with ideal pregnancy weight gain ranging from 7-11 kg for overweight and 5-9 kg for obese women. Lifestyle-related risks include habitual smoking, tobacco use, and alcohol consumption. Medical conditions such as severe anemia (Hb <7.0 g/dL) and chronic illnesses, including diabetes, hypertension, thyroid dysfunction, heart disease, cancer, asthma, and kidney disease, further elevate risk. Obstetric complications such as grand multiparity (≥5 births), short (<18 months) or extended (>59 months) birth intervals, prior preterm deliveries (<37 weeks), negative obstetric history (miscarriage, stillbirth, abortion), and previous cesarean sections are also significant contributors.⁵

Psychological challenges and high-risk pregnancy

Women experiencing high-risk pregnancies are significantly more vulnerable to emotional and psychological challenges, particularly stress, anxiety, and depression.⁶ Studies suggest that 6-17% of pregnant women report high stress levels, while 14-92% experience mild to moderate stress during pregnancy, with elevated stress linked to adverse outcomes such as preterm birth and low birth weight.^7,8 These risks are further compounded by prolonged hospitalizations and separation from family, leading to emotional distress and fears surrounding fetal well-being.⁹ Women may experience a complex range of emotions from fear, guilt, and helplessness to moments of joy and hope, reflecting the multifaceted nature of high-risk pregnancy.

Antenatal anxiety, a psycho-biological condition influenced by hormonal fluctuations (notably in estrogen and progesterone), tends to increase as pregnancy progresses. Anxiety is often more prevalent than depression during pregnancy and may co-occur or precede postnatal depression, especially in high-risk cases.¹⁰ Hospitalization, medical uncertainty, and a lack of control further exacerbate this anxiety, potentially affecting both maternal mental health and neonatal outcomes. Despite its significance, research on antenatal anxiety, particularly in high-risk pregnancies, remains limited compared to the focus on postnatal depression.¹¹

Coping mechanisms in high-risk antenatal women: strategies for emotional resilience

In high-risk pregnancies, coping strategies play a vital role in managing emotional, physiological, and cognitive responses to stress. Effective coping not only helps reduce immediate distress but may also act as a protective factor, shielding both mother and fetus from the long-term effects of prenatal stress. Coping approaches are generally categorized into two main types: problem-focused and emotion-focused. Problem-focused coping involves actively addressing or resolving the source of stress and is typically adopted when the situation is perceived as controllable. In contrast, emotion-focused coping aims to alleviate emotional distress and is more common when the stressor is seen as uncontrollable.¹² Additionally, coping strategies can be classified into engagement (approach) coping, which involves confronting the stressor directly or indirectly, and disengagement (avoidance) coping, which seeks to escape or distance oneself from the stressor.¹³ Avoidance strategies are often considered a form of emotion-focused coping, as they involve efforts to evade the discomfort associated with stress.¹⁴ Although these classification systems simplify a broad range of coping behaviors, they remain widely used in research and have contributed valuable insights into how pregnant women manage high-risk conditions. High-risk pregnancies are often accompanied by significant psychological distress, including heightened levels of stress and anxiety. However, existing literature tends to focus more on physical outcomes, with limited attention to emotional well-being and coping mechanisms. This review addresses that gap by synthesizing current evidence on psychological challenges and coping strategies among high-risk pregnant women. It also highlights the need for integrating mental health support into routine antenatal care.

The current review primarily focused on examining the psychological challenges, specifically stress and anxiety, experienced by women during high-risk pregnancies, and how they cope with these challenges. It also emphasized the impact of coping strategies on maternal and fetal outcomes, and explored practical, evidence-based interventions that can be integrated into antenatal care to support the mental well-being of this vulnerable population.

Objectives of the current narrative review are: 1. To explore the psychological challenges, particularly stress and anxiety, faced by women during high-risk pregnancies and their contributing factors. 2. To examine the coping strategies adopted by high-risk pregnant women and their impact on maternal mental health and pregnancy outcomes. 3. To identify evidence-based interventions and practical approaches for integrating psychological support into antenatal care for high-risk pregnancies.

Magnitude and determinants of stress in high-risk pregnancies

Stress is a predominant psychological response in high-risk pregnancies, reported in 6-17% of pregnant women at high levels and 14-92% at mild to moderate levels, depending on the context and measurement tools used. High stress has been strongly associated with adverse perinatal outcomes, including preterm delivery and low birth weight. Determinants of stress include uncertainty regarding fetal outcomes, chronic illnesses, obstetric complications, prolonged hospitalization, and separation from family members, which add to emotional strain and perceived helplessness.^15,16

A quasi-experimental study in Iran found that education interventions significantly reduced perceived stress and anxiety in high-risk women awaiting amniocentesis.¹⁷ Similarly, studies suggest that hospital-based mindfulness and relaxation techniques can alleviate stress and autonomic dysregulation [Table 1].^18,19 Sociodemographic factors such as low education, poor social support, and unemployment further compound the experience of stress.²⁰

Antenatal anxiety in high-risk pregnancies: Scope and impact

High-risk pregnancies are associated with increased hospitalization, medical uncertainty, and hormonal fluctuations, all of which may elevate anxiety symptoms. Antenatal anxiety commonly manifests as excessive worry about the baby’s health and survival, fear of pregnancy complications, sleep disturbances, restlessness, irritability, and difficulty concentrating.²¹

Studies from Singapore and Greece²² report high rates of anxiety among hospitalized high-risk pregnant women, with significant psychological consequences for both mother and fetus.

Hormonal influences, particularly changes in estrogen and progesterone, contribute to heightened emotional sensitivity and anxiety in late pregnancy. In a study, Giurgescu et al. highlighted the role of perceived uncertainty and inadequate coping in exacerbating psychological distress during high-risk pregnancies [Table 1].²³

Innovative interventions such as midwife-led psychoeducation [Table 1]²⁴ and mindfulness-based stress reduction (MBSR)¹⁹ [Table 1] have shown statistically significant improvements in anxiety symptoms and maternal-fetal attachment. Despite these advances, antenatal anxiety remains under-researched compared to postnatal depression, especially in high-risk obstetric contexts.

Coping strategies in high-risk pregnancies: Adaptive vs. maladaptive approaches

Coping strategies play a central role in moderating the psychological impact of high-risk pregnancies. Adaptive strategies, such as emotional support-seeking, problem-solving, and cognitive restructuring, have been linked to improved psychological well-being and maternal outcomes.^16,25,26 Conversely, maladaptive coping (e.g., denial, withdrawal, substance use) correlates with increased distress and poorer perinatal outcomes.

A randomized controlled trial by Ibıcı Akca et al. demonstrated that mindfulness-based coping interventions improved prenatal attachment and reduced both anxiety and stress [Table 1].¹⁹ Similarly, a Turkish study on women with hyperemesis gravidarum reported that coping ability and adaptation to pregnancy were significantly enhanced through psychosocial support programs.²⁷

A randomized controlled trial found that coping style mediates the relationship between psychological distress and maternal health, recommending that healthcare providers incorporate routine assessment of coping mechanisms into antenatal care protocols [Table 1].²⁵

Sociodemographic determinants

Multiple studies have identified various sociodemographic factors that may influence stress and anxiety in pregnant women. Commonly assessed variables include maternal age, marital status, education level, experience of intimate partner violence, household income,²⁸ and household size.²⁹ Other influential factors include the type of pregnancy (planned or unplanned), maternal occupation, working hours, family structure (nuclear or joint), level of social support,³⁰ and urban or rural place of residence.³¹ These factors have been investigated in relation to perceived stress scores (PSS), antenatal anxiety, and overall emotional well-being during pregnancy.

Clinical determinants

Clinical variables also play a significant role in influencing stress and anxiety levels among pregnant women. Key clinical determinants include gravidity (number of pregnancies), parity (number of live births), type of pregnancy (singleton or multiple), mode of previous delivery,³² history of abortion, and prior obstetrical complications.³⁰

Correlations between sociodemographic, clinical factors, and psychological outcomes

Research findings on the association between sociodemographic and clinical factors and maternal mental health have yielded mixed results. For instance, age, marital status, education, and parity did not show a statistically significant relationship with stress levels in some studies. However, age was found to be positively correlated with anxiety, suggesting that older pregnant women tend to experience greater anxiety. Neither the educational background of the mother and her spouse nor the mother’s occupation appeared to influence anxiety levels meaningfully.

On the other hand, gestational age was identified as a significant predictor of anxiety, with later stages of pregnancy linked to higher anxiety scores. Women with multiple pregnancies (higher gravida) and more live births (higher parity) also reported increased anxiety. Furthermore, a history of abortion and previous obstetrical complications were associated with elevated anxiety symptoms. Notably, the presence of strong social support was linked to lower anxiety levels, emphasizing its crucial role as a protective factor during the antenatal period.³³

Implications for practices

Despite growing recognition of the psychological burden of high-risk pregnancies, there remains a significant gap in targeted research and standardized interventions. Evidence supports the integration of mental health screening, psychoeducation, and structured coping interventions within antenatal care, particularly for high-risk cases. Digital health platforms, such as e-mindfulness programs,²¹ and non-pharmacologic therapies like aroma inhalation¹⁸ or relaxation training,³⁴ represent scalable solutions. Collaborative efforts among midwives, obstetricians, psychologists, and policy-makers are essential to address these psychological needs comprehensively.