December 6, 2020

Supportive Counseling and Its Impact on Expecting Mothers

by Layla Langdon, Doctor of Pharmacy Student, University of Mississippi School of Pharmacy

Summary and Analysis of: Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304 

This article caught my attention because we have been studying women’s health and the impact of the mother’s behaviors and stress on a developing baby. Also, as a student pharmacist, I am very interested in pursuing a career in pediatrics, and a child’s health really starts in the womb. This study attempted to demonstrate the impact of an educational support program on a woman’s pregnancy-related and general stress as well as prenatal health behaviors. Pregnancy-related stress is often the result of worrying about maternal and fetal health, parental responsibility, physical symptoms, labor pain, childbirth, and the cost of raising a child.1 All of these factors weigh on a woman and starts to take a toll on her health and can lead to a poor pregnancy outcome. Using supportive counseling to supplement usual antenatal care, this study aimed to reduce maternal stress and promote healthy behaviors that would benefit the mother and the developing child.

To test this theory, pregnant women between gestational age 6 and 32 weeks with no comorbidities were recruited to participate in this randomized, control study. The participating women were divided into two groups with 40 participants each. Women in both groups completed four questionnaires at baseline including the Revised Prenatal Distress (NUPDQ), Spielberger State-Anxiety Inventory (STAI-Y), Prenatal Health Behaviors Scale (PHBS), and the Perceived Stress Scale (PSS-14).  In addition, all of the women provided a saliva sample to measure salivary cortisol concentration. Each participant was advised to fast and avoid alcohol for at least 24 hours before the salivary sample was taken. Changes in the NUPDQ, STAI-Y, and PHBS were the primary outcomes for this study, and the PSS-14 and the salivary cortisol assay were considered secondary outcomes.

The control group received only usual antenatal care based on Iranian national guidelines. Each participant in this group received midwifery examinations, assessments of the mother’s and fetus’s health, and education about personal hygiene, sexual activity, signs of a high-risk pregnancy, common pregnancy complaints, nutritional and medicinal supplements, and use of fertility health services. In addition to usual antenatal care, the intervention group received weekly supportive counseling conducted by a female expert psychologist. These supportive counseling sessions consisted of face-to-face instruction with 12 to 14 women in each group. This gave the women the opportunity to interact with one another.  During these sessions, they discussed their stress and anxiety.  The instructor also designed group work and guided exercises to address unhealthy behaviors. The program targeted pregnancy-related worries such as health problems and costs, parental responsibility, physical symptoms, infantile health, parenting, labor pain, and childbirth phobia. Six weeks after completing the educational program, all participants in both groups again completed the four questionnaires and provided a salivary sample to measure their cortisol.

The results revealed there were significant improvements in the mean NuPDQ, STAI-Y, PHBS, and PSS-14 scores in the intervention group, including in the subscales of these instruments, when compared to the control group. Specifically, there were large effect size improvements in the medical and financial problems, infant health, physical symptoms, and labor and delivery subgroups of the NuPDQ and the four subgroups of the PHBS (See Table 1). The salivary cortisol levels improved in both the intervention and control groups but there were no significant differences in the mean change observed. 

Table 1. Mean Pre (T0) and Post (T1) Scores and Differences for Selected Outcomes Following an Educational Support Program for Pregnant Women





T0 Mean

T1 Mean


T0 Mean

T1 Mean


Primary Outcomes






















Harmful Behavior of Health







Health Promoting Behavior







Harmful Physical activity of Health







Health Promoting Physical activity







Secondary Outcomes








Serum Cortisol







One of the strengths of this study was the use of four different questionaries to evaluate the effect of supportive counseling on pregnancy-specific, general stress, and healthy behaviors. Another strength of this study is that the supportive counseling provided to the experimental group was provided in small groups with only 12 to 14 participants per group. This allowed each participant to develop relationships with other pregnant women who may be experiencing the same struggles. This study also aimed at improving each participant's self-esteem and maximizing their adaptive skills. These are important objectives because pregnant women often feel incapable of birthing and raising a child. The weaknesses of this study are that the questionnaires used were all based on self-evaluation. The authors do not discuss the sustainability of the program and don’t report outcomes after delivery – so the health outcomes of the babies is unknown. The findings of this study probably should not be generalized to complicated pregnancies.  While salivary cortisol was included as a measurement of stress, it does not correlate well with psychological stress.

In future studies, it would be helpful for each participant to complete a session with a mental health professional. This would allow a more personalize assessment and help the participants identify and analyze the specific stressors they are experiencing. Also, the addition of this session could be used as an external evaluation. Although this is a subjective measurement similar to the self-evaluations, an assessment performed by a mental health professional would be consistent for all participants. Future studies should gather data through the entire pregnancies, including delivery, plus three months postpartum.  This is important to truly determine the long-term effect of supportive counseling on pregnancy-related stress and outcomes.

A similar study analyzed the effect of a supportive intervention in pregnant women who were depressed using the Postnatal Depression Scale (EPDS >12).3 In this study, the intervention group received the same number of counseling sessions, six visits, but over eight weeks. That study also concluded that supportive counseling in addition to usual prenatal care improved outcomes. Specifically, the participants reported improvements in depressive symptoms, depressive severity, and quality of life. Another study found that supportive counseling improved the patient’s satisfaction during delivery.4 Although these studies had minor differences in terms of the number of counseling sessions provided, the program duration, and the number of participants, they all concluded that supportive counseling subjectively improved pregnancy-related stress 

While the supporting counseling program appears to have been effective, it would have been helpful if the intervention were described in more detail. This would allow other health professionals, such as pharmacists and nurses, to implement a similar program. However, this study is important because it demonstrated the benefits of adding supportive counseling to usual prenatal care. This may also improve the health of the fetus and allow for a smoother birthing experience. Overall, I believe that providing supportive counseling to pregnant women should be the standard of care during all pregnancies.



  1. Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304.
  2. Nast I, Bolten M, Meinlschmidt G, Hellhammer DH. How to Measure Prenatal Stress? A Systematic Review of Psychometric Instruments to Assess Psychosocial Stress during Pregnancy. Paediatric and Perinatal Epidemiology. 2013;27(4):313–22.
  3. Neighmond P. To Prevent Pregnancy-Related Depression, At-Risk Women Advised To Get Counseling [Internet]. National Public Radio. NPR; 2019 [cited 2020Oct19].
  4. Segre LS, Brock RL, O'Hara MW. Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial. J Consult Clin Psychol 2015; 83 (2): 314-24.
  5. Pasha H, Basirat Z, Hajahmadi M, Bakhtiari A, Faramarzi M, Salmalian H. Maternal expectations and experiences of labor analgesia with nitrous oxide.. Iranian Red Crescent Med J 2012; 14 (12): 792-7.

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