Document Type : Original Article


1 Research Center for Nursing and Midwifery Care, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

2 Assistant Professor of Psychiatry Shahid Sadoughi University of Medical Sciences, Yazd, Iran

3 Department of Biostatistics and Epidemiology, Public Health College, Shahid Sadoughi University, Yazd, Iran

4 Department of Midwifery, Maybod Branch, Islamic Azad University, Maybod, Iran


BACKGROUND: Pregnant women are classified as one of the vulnerable groups. Physiological and
psychological changes during pregnancy predispose them to serious psychiatric disorders; if not
identified and treated in time, it can have a negative and long‑term impact on mental health. The aim
of this study was to determine the effect of cognitive–behavioral counseling of pregnant women with
the presence of a spouse on the level of stress, anxiety, and postpartum depression.
MATERIALS AND METHODS: The present study is a clinical trial that was performed on 40 pregnant
women with a gestational age of 32–28 weeks (20 in the intervention group, 20 in the control group)
who were randomly assigned to the intervention group and the control group according to the inclusion
criteria. Cognitive–behavioral group counseling in the presence of spouses was performed by the
midwife and under the supervision of a psychologist, in eight sessions, each session lasting 90 min,
once a week for the intervention group. The control group received routine care and a counseling
session. Data collection tools were demographic information questionnaire and Depression–Anxiety–
Stress Scale 21, which were completed before the intervention, immediately after the intervention,
and on the 14th day after delivery in both groups. Data analysis was performed using statistical tests,
independent t‑test, repeated measures test, Bonferroni post hoc test, and Kolmogorov–Smirnov test.
RESULTS: The results of this study showed that the mean scores of stress, anxiety, and depression
in the two groups in the preintervention stage were not significantly different (P < 0.05), but in the
postintervention stage and follow‑up, the mean scores of stress (P < 0.001), depression (P = 0.010),
and anxiety (P = 0.029) in the intervention group were significantly reduced compared to the control
CONCLUSION: According to the research findings, cognitive–behavioral group counseling can be
effective as an approach in improving the symptoms of stress, anxiety, and depression in pregnant
women. Therefore, it is necessary to plan properly to use this counseling approach to manage stress,
anxiety, and depression in women during pregnancy.


  1. Qutaiba A, Qutaiba A, Yazan B, Mohammad S, Najlaa I,
    Hayder K, et al. Perinatal depression. Prevalence, suicidal idea,
    and associated factors. J Pharm Sci Res 2020;21:112‑8.
    2. Tiki T, Taye K, Duko B. Prevalence and factors associated with
    depression among pregnant mothers in the West Shoa zone,
    Ethiopia: A community‑based cross‑sectional study. Ann General
    Psychiatry 2020;19:24.
    3. Mohamadi M, Kamal SH, Vameghi M, Rafiey H, Forouzan AS,
    Sajjadi H. A meta‑analysis of studies related prevalence of
    depression in Iran. J Res Health 2017;7:581‑93.
    4. Afshari P, Tadayon M, Abedi P, Yazdizadeh S. Prevalence and
    related factors of postpartum depression among reproductive aged
    women in Ahvaz, Iran. Health Care Women Int 2020;41:255‑65.
    5. Azami M, Badfar G, Shohani M, Mansouri A, Soleymani A,
    Shamloo MB, et al. The prevalence of depression in Iranian
    pregnant women: A systematic review and meta‑analysis. Iran J
    Psychiatry Behav Sci. 2018;5 (2):41‑149.
    6. Gürkan ÖC, Ekşi Z. Effects of antenatal education program on
    postpartum functional status and depression. Clin Exp Neurol
    7. Khaledian M, Gharibi H, Gholizadeh Z, Shakeri R. The impact of
    group cognitive behavioral therapy (CBT) on depression decrease
    and hopefulness increase of empty nest syndrome. J Fam Couns
    Psychother 2013;3:261‑79.
    8. Wahed WY, Hassan SK. Prevalence and associated factors of
    stress, anxiety and depression among medical Fayoum University
    students. Alex J Med 2017;53:77‑84.
    9. Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The
    prevalence of anxiety disorders during pregnancy and the
    postpartum period: A multivariate Bayesian meta‑analysis. J Clin
    Psychiatry 2019;80:18r12527.
    10. Punamäki RL, Repokari L, Vilska S, Poikkeus P, Tiitinen A,
    Sinkkonen J, et al. Maternal mental health and medical predictors
    of infant developmental and health problems from pregnancy
    to one year: Does former infertility matter? Infant Behav Dev
    11. Nolvi S, Karlsson L, Bridgett DJ, Korja R, Huizink AC, Kataja EL,
    et al. Maternal prenatal stress and infant emotional reactivity six
    months postpartum. J Affect Disord 2016;199:163‑70.
    12. Smorti M, Ponti L, Tani F. Maternal depressive symptomatology
    during pregnancy is a risk factor affecting newborn’s health:
    A longitudinal study. J Reprod Infant Psychol 2019;37:444‑52.
    13. Green SM, Haber E, Frey BN, McCabe RE. Cognitive‑behavioral
    group treatment for perinatal anxiety: A pilot study. Arch
    Womens Ment Health 2015;18:631‑8.
    14. Baucom DH, Fischer MS. Cognitive behavioral couple therapy.
    In: In: Lebow J.L., Chambers A.L., Breunlin D.C. (eds),
    Encyclopedia of Couple and Family Therapy . Springer, Cham.
    2019. p. 489‑97.
    15. Montazeri A, Omidvari S, Azin A, Ayeenparast A, Jahangiri K.
    Sedighi Z, et al. Happiness among Iranian: Findings from the
    Iranian health perception survey. Payesh 2012;11:467‑75.
  2. 16. Akbarzadeh M, Toosi M, Zare N, Sharif F. Effect of relaxation and
    attachment behaviors training on anxiety in first‑time mothers in
    Shiraz city, 2010: A randomized clinical trial. Qom University Of
    Medical Sciences Journal, 2013;6(4) (24);14 ‑23.
    17. Samani S, Joukar B. A study on the reliability and validity of
    the short form of the depression anxiety stress scale (Dass‑21).
    Journal Of Social Sciences And Humanities Of Shiraz University
    l 2007;26,3(52): 65‑77.
    18. Hofmann SG, AsnaaniA, Vonk IJ, SawyerAT, FangA. The efficacy
    of cognitive behavioral therapy: A review of meta‑analyses.
    Cognit Ther Res 2012;36:427‑40.
    19. Saleh J, Mahmoudi O, Paydar M. Efficacy of cognitive‑behavioral
    therapy on the reduction of depression among students. Q J Child
    Ment Health 2015;2:83‑8.
    20. Salehi F, Pourasghar M, Khalilian A, Shahhosseini Z. Comparison
    of group cognitive behavioral therapy and interactive lectures in
    reducing anxiety during pregnancy: A quasi experimental trial.
    Medicine 2016;95:e5224.
    21. Bittner A, Peukert J, Zimmermann C, Junge‑Hoffmeister J,
    Parker LS, Stöbel‑Richter Y, et al. Early intervention in pregnant
    women with elevated anxiety and depressive symptoms: Efficacy
    of a cognitive‑behavioral group program. J Perinat Neonatal Nurs
    22. Gamble J, Creedy D, MoyleW, WebsterJ, McAllister M, Dickson P.
    Effectiveness of a counseling intervention after a traumatic
    childbirth: A randomized controlled trial. Birth 2005;32:11‑9.
    23. Wright JH, Brown GK, Thase ME, Basco MR. Learning
    Cognitive‑behavior Therapy: An Illustrated Guide. Philadelphia,
    PA: American Psychiatric Association Publishing; 2017.
    24. BurnsA, O’MahenH, BaxterH, BennertK, WilesN, RamchandaniP,
    et al. A pilot randomised controlled trial of cognitive behavioural
    therapy for antenatal depression. BMC Psychiatry 2013;13:33.
    25. Andaroon N, Kordi M, Kimiaee SA, Esmaily H. Effect of
    Individual Counseling Program by a Midwife on Anxiety during
    Pregnancy in Nulliparous Women. Iran J Obstet Gynecol Infertil
    26. Sockol LE. A systematic review of the efficacy of cognitive
    behavioral therapy for treating and preventing perinatal
    depression. J Affect Disord 2015;177:7‑21.
    27. Aghdasi A. The effect of individual and group counseling based
    on reversal theory in decreasing athletes stress. Journal Of
    Psychology (Tabriz University) 2010; 5 (18) :31 ‑49.
    28. O’Mahen H, Himle JA, Fedock G, Henshaw E, Flynn H. A pilot
    randomized controlled trial of cognitive behavioral therapy for
    perinatal depression adapted for women with low incomes.
    Depress Anxiety 2013;30:679‑87.
    29. Barbato A, D’Avanzo B. Efficacy of couple therapy as a treatment
    for depression: A meta‑analysis. Psychiatr Q 2008;79:121‑32.