Introduction

The secure attachment style is directly related with better relationship loyalty, trust and dependence upon each other. Attachment styles are systematic patterns of relational expectations, emotions and behavior [1]. Bartholomew and Horowitz explained four attachment styles that are based upon the positive and negative changing in the working model of self and other [2]. Hazan and Shaver said, bond that form during the infancy have great effect on attachment styles on adulthood [3]. Anxiety and avoidance are two fundamental dimensions that are used to explain the styles of attachment [2,4-6].

In interpersonal relationship in which a person has the positive view of self and other is called secure attachment. It is characterized by mutual dependence within a relationship, trust, and close emotional intimacy [2]. Securely attach person experience low anxiety and low avoidance in their close relationship. According to Simpson individuals with secure attachment report dependence, commitment, higher level of interdependence and over all relationship satisfaction [7]. When a mother is well supported and happy, she is capable to give a spontaneous birth of an infant without taking medicines and all these things ensure that baby is well adjusted after their birth and socially responsible [8].

Fearful attachment style makes an individual to develop unconstructive (negative) analysis of oneself as well as unconstructive (negative) analysis of others. Fearful individual believe in distress of intimacy. In preoccupied attachment style individual has positive view of others and negative view of one self. They report high anxiety and low avoidance in their interpersonal relationship. People with preoccupied style of attachment base their self-respect on either an important person in their lives will accept them. Dismissing attachment style is characterized by a positive view of self and a negative view of others. They feel high avoidance and low anxiety in romantic relationships.

These people have negative perception of others, honesty and responsiveness. They save themselves by maintaining the independent relationship and remain far away from close relationship [2]. During pregnancy a women need a consistent love, care and support from people around like husband or family. When she is supported and protected by other she may able to give birth of a child without complication and bond between the infant and mother is healthy [8]. Death anxiety is define as uneasiness generated by death knowledge [9]. Previous researches suggested death anxiety produce emotional, psychical and behavioral outcome [10]. Women with the histories of repeated unplanned abortion, early infant delivery or death lead towards poorer life quality and facing more death anxiety and depression at the time of their following pregnancy, as compare to those without such previous circumstances.

The maternal mortality rate (MMR) in Pakistan is 500 deaths per 100,000 births, at the same time it is highest within the contrary in Baluchistan at 673 [11]. Pregnant women experience variety of emotional changes which cause anxiety. Studies shows low satisfaction with the partner relationship was the most important risk factors for anxiety or depression symptoms in pregnancy. Good partner relationship seemed to acts as a “buffer” against adverse effect stressors such as physical illness, low income and difficult working condition [12].

According to department of health policy paper in Pakistan gender awareness policy appraisal in 2006, one of the majority reasons for this high maternal mortality rate was malnutrition. According to Mikulincher and Florian individuals with secure and avoidant attachment styles show less fear of death as compare to anxious individuals, ambivalent and avoidant individuals had low fear of death as compare to individuals with secure attachment [13].

Variables like social support, attachment relationships, isolation, and bereavement, have long been considered to add to the risk of developing anxiety, depression and individual differences in patterns of interpersonal interaction may help to explain why some people become depressed and feel death anxiety when they are ill and others do not. Attachment theory is a particularly well developed interpersonal theory that may describe the ways that people use close interpersonal relationships to achieve a sense of security [14].

Rationale of the study

Pregnancy has brought the remarkable emotional and psychological changes for the women. Death anxiety and depression are more prevalent in pregnancy. Women with the history of psychological problems in their family, suffering past psychological and gynecological problem, lack of family support suffer more mental disorders in pregnancy. Anxiety related to death has affected both mother and child therefore it is necessary to approximate the prevalence of anxiety. Only handful of studies on this topic from Pakistan can explain the phenomenon. In conservative patriarchal country, difficulty in marital relationship act as contributing to Common Mental Disorders (CMDs). Mental disorder is common in women having the age of 35 years than older married women [15]. Impaired mental health (with anxiety and depressive symptoms) is associated with unhealthful maternal gynecological behavior which include reduced prenatal care and lower weight gain in pregnancy are included which in turn lead to cause hormonal imbalance and make the women more anxious than usual. Anxiety due to other circumstances should be treated during pregnancy [16]. Before birth of a child anxious style are known to be important in pregnancy, leaving negative effect on the support of other and partner [17]. Women with first pregnancy and insecure style report great intensity of psychological pain as compare to mothers to be with secured attachment style.

Hence, it is important to investigate the attachment style of pregnant women in relation to death anxiety so that it may helpful for the clinicians and mental health professionals as well for the family to get awareness about the statement of pregnant women and give additional support and better medical facilities.

Objectives

1. To explore the relationship between death anxiety and attachment styles among pregnant women.

2. To explore the differences across demographics for example age, number of pregnancies and pregnancies loss along with study variables.

Hypotheses

1. Death anxiety is positively correlated with Anxious and Avoidant attachment style among pregnant women.

2. Younger pregnant women score high on preoccupied, fearful and dismissing attachment style as compare to older age pregnant women.

3. Women with the first pregnancy score high on anxious, fearful and dismissing attachment style as compare to women with second and third pregnancy.

4. Pregnant women with the history of pregnancy loss experience more anxiety as compare to pregnant women with no history of pregnancy loss.

Sample

The sample of the present study consists of 62 pregnant women with age ranges from 18-45 years recruited through purposive convenient sampling technique from different hospitals of Islamabad (Shifa Medicine Hospital, and Polyclinic) and Rawalpindi (Maryam Memorial Hospital and Cantonment Hospital). Categories of sample made as the following; women with the first pregnancy (n=14), second and third pregnancy (n=11), fourth and onward (n=17). Women with the pregnancy loss (n=11) and women with no pregnancy loss (n=51). Data has been taken only from those pregnant women who were volunteer to participate in the current study.

Measures

Following measures were used to assess the attachment styles and death anxiety among pregnant women.

Experience in Close Relationship-Revised (ECR-R) Questionnaire

Experiences in close relationships questionnaires (ECR-R) is developed by Brennan, Clark, and Shaver’s, revised by Fraley, Weller, and Brennan [6,18]. It contains 36 items and likert type self-report that calculate of adult attachment. It has two subscales and each subscale consists of 18 items. Anxiety scale consists of 18 items with maximum score of 126 and minimum score of 18. Items No. 4, 5, 9, 10, 11, 12, 17, 18, 19, 20, 21, 22, 23, 24, 28, 29, 33, and 36 are include in it. Avoidance scale consists of 18 items with maximum score of 126 and minimum score of 18. Items No. 1, 2, 3, 6, 7, 8, 13, 14, 15, 16, 25, 26, 27, 30, 31, 32, 34, 35. High scores on anxiety and avoidance subscales represents high anxiety and vice versa. Internal consistency reported as .90 or higher for the two ECR-R scales (i.e., Avoidance and anxiety). Each item is rated on seven point scale where one equal to strongly disagree, 2: Disagree, 3: Slightly disagree, 4: Neutral, 5: Slightly disagree, 6: Agree, 7: Strongly agree. These items 4, 5, 9, 11, 12, 17, 18, 19, 24, 26, 27, 29, 33 and 36 are reverse scores (i.e., 7: Strongly disagree to 1: Strongly agree).

Maximum score on this scale is 252 and minimum score is 36. Similarly the maximum score for each subscale is 26 and minimum is 18. Two dimension model of attachment used in this measure categorize into four styles of attachment i.e., Secure attachment style, Fearful attachment style, Preoccupied attachment style, and Dismissing attachment style.

Death Anxiety Scale

The Death Anxiety Scale develops by Goreja and Perved consist of 20 item relating to the few of personal death [19]. This item include in the scale were categorized into six dimension of death anxiety i.e., concern over suffering and lingering death (Item no. 5); subjective proximity to death (Item no. 19); disturbing death thoughts (Items no. 1, 3, 4, 6, 7, 11, 12, 13, 15, 18); impact on the survivor (Item no. 9); fear of punishment and (Items no. 2, 8, 10 17, 20) and fear of not being (Items no. 14, 16). All items were score positively.

Responses were obtained on five point scale with highest possible score of 100 and lowest possible score of 20 with cut off score of 50. The response categories range from always to never. Where mostly (5), frequently (4), sometime (3), rarely (2), and never (1). The scale were found internally consistence with α=0.89.

Procedure

After finalization of instruments. Permission was taken from Institutional Review board. And also from the higher authorities of hospitals from where data was collected. The data was collected from the private and government hospital of Rawalpindi and Islamabad. Those pregnant women who fall on the inclusion criteria were identified. Some of the pregnant women were personally contacted and some of them were approached with the help of authorities of the center.

Results

In order to meet the present study objectives correlation, Chi-square analysis and t-test were conducted.

Results indicated that alpha reliability of ECR-R and anxious scale are reasonable, scale is reliable measure. The subscale of ECR-R (anxiety and avoidance) are positively correlate with each other. Pearson correlation indicates that all subscale and total of ECR-R have a significant positive relationship with death anxiety scale.

Table 1: Mean, standard deviation, alpha reliability and correlation of experience in close relationship-revised questionnaire and death anxiety scale. *: p<0.05. **: p<0.01. Note: ECR: Experience in Close Relationship, DA: Death Anxiety

Table 2 shows the chi square (χ2) values. It reveals that there are significant difference exist between attachment styles of the pregnant women along with ages. The young pregnant women with age rang 18-32 years score high on fearful, preoccupied attachment style as compare to older age women. The results are significant on 0.01 levels.

Table 2: Frequencies and Percentage of Pregnant Women Attachment Styles along with Ages.
**: p<0.01, df: 4

Table 3 shows the chi square (χ2) values. There is a significant difference between number of pregnancies and attachment styles. Women with first pregnancy were high on fearful, dismissing, and preoccupied attachment style.

Table 3: Frequencies and percentages of attachment styles of pregnant women along with first, second and third pregnancy. **: p<0.01. *: p<0.05, df: 6.

Table 4 shows Death anxiety of pregnant women on the basis of Pregnancy loss. Significant mean difference are found in Death Anxiety of pregnant women with the history of Pregnancy loss (n=11) and pregnant women with no history of pregnancy loss (n=51). Pregnant women with histories of pregnancy loss indicate high level death anxiety as compare to pregnant women with no history of pregnancy loss.

Table 4: Mean standard deviation and t value for death anxiety among the pregnant women having pregnancy loss and women having no history of pregnancy loss. Note: DA: Death Anxiety Scale; CL; confidence interval; LL: Lower Limit; UL: Upper Limit

Discussion

The present study aimed at investigating the relationship between attachment styles and death anxiety among pregnant women in Pakistan. In order to meet the study objectives Experience in close relationship-revised questionnaire and death anxiety scale used to measure attachment styles and death anxiety among pregnant women. Correlation and Chi-square test were conducted in order to reach the conclusion. It has been found that all the subscale has a significant positive relationship with one another and total scale score. Psychometric properties found by previous researches are in line with the present research [18,20] that two subscale correlate significantly each other and correlation between anxiety and avoidance scale was 0.41 and 0.90.

It has been revealed that attachment styles (anxious and avoidant) is positively related with death anxiety among pregnant women were supported in the current investigation. According to Mikulincher and Florian pregnant women with secure attachment style show lesser death fear as compare to women with anxious and avoidant attachment styles [13]. Person with the anxious attachment style fear of their societal identity loss at death, Unknown type of mortality is associated with avoidant style of attachment.

Young Pregnant women show more fearful, preoccupied and dismissing attachment style as compare to older age pregnant women. Especially in younger mother, high rates of violence, husband (partner) nonattendance and relational problem are present [21]. Pregnant teenagers with first pregnancy are more disadvantaged group because they are with lowest formal education and mostly from low economic class, and more often to be a single in their first pregnancy. Young pregnant women are higher level of destruction because of insecure style of attachment especially fearful, enmeshed and dismissive [22]. Results have also revealed that women with the first pregnancy were high on anxious, fearful and dismissing attachment style as compare to women with second and third pregnancy. Women having the first pregnancy were high on insecure attachment style as compare to women having second and third pregnancy. Insecure attachment style has unconstructive impact on the support and relationship with other and is predominate when a women is pregnant [17,23].

Pregnant women with the history of pregnancy loss feel more anxiety as compare to pregnant women with no history of pregnancy loss. Cohens’d (1.20) indicate the strength of the relationship between pregnant women with pregnancy loss and pregnant women with no pregnancy loss along with death anxiety. Pregnant women with pregnancy loss feel more death anxiety as compare to pregnant women with no history of pregnancy loss. Women with the histories of fetal death, repeated unplanned abortion, early infant delivery or death lead towards poorer life quality, experience of death anxiety and depression at the time of their following pregnancy, as compare to those without such previous circumstances. Anxiety over the childbirth is not associated with disbelief in staff, lack of skills of female and death fear. Pain terror is not predominant although important to some extant in pregnancy [24]. Due to miscarriages women have higher level of pregnancy-related fear and anxiety. Fear about pregnancy has negative impact on the women and it may interfere at delivery. Therefore, interventions to minimize pregnancy-related fear are highly suggested [25].

Conclusion

The present research was designed to explore the attachment styles and death anxiety among pregnant women. Consistence with the proposed hypotheses, the findings of the current study revealed that attachment style is positively correlated with death anxiety among pregnant women, young pregnant women were high on anxious and fearful styles of attachment as compare of older age women. Women with the first pregnancy were high on anxious, dismissing and fearful attachment style as compare to women with second and third pregnancy. Results also have shown that pregnant women with history of pregnancy loss feel more death anxiety as compare to pregnant women with no history of pregnancy loss. Intimate bad relationships with husbands, a lack of practical support have negative impact on pregnant women.

Theoretical and Practical Implications

The study indicates the necessity of integrating mental health with existing maternal and child health care in Pakistan. All those concerned with antenatal care need to pay attention and screen for death anxiety symptoms. Policies aimed at referring women with death anxiety symptoms to the nearest medical college hospital where psychological treatment is freely provided may help mothers in receiving appropriate support. Providing practical support to women during pregnancy, particularly those with a previous history of depression, mental disorder reducing gender-based violence, and supporting women in poor partner relationship are important preventive strategies to adopt at the community level.

Conflict of Interest

Authors declared no conflict of interest.

Funding

It is declared that authors received no funding from any agency, any person or organization.

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