General Health and Psychological Symptom

Status in Pregnancy and the Puerperium:

What Is Normal?
FELICIA OTCHET, PhD, MARK S. CAREY, MD, AND LORRAINE ADAM, MSW
Objective: To identify normative changes in psychological
and physiologic health status associated with pregnancy and
the puerperium.
Methods: Self-administered surveys containing Wares
Short Form-36 and Derogatiss Brief Symptom Inventory
were completed by 393 pregnant women during their third
trimester. Of those, 253 completed the same survey during
the puerperium. Results were compared between periods
and with those of samples of women from standardized
community samples.
Results: On the Short Form-36, pregnant women in the
third trimester had significantly poorer levels of functioning
(P < .01) than community controls with regard to bodily
pain (51.86 versus 79.61), physical functioning (62.91 versus
89.12), social functioning (74.0 versus 84.06), vitality (47.24
versus 58.04), and functional limitations resulting from
physical health problems (45.0 versus 86.73) subscales.
Those differences persisted into the puerperium. Compared
with pregnancy, scores on social functioning and functional
limitations caused by emotional problems decreased during
the puerperium. Women reported improved perceptions of
their general health in the puerperium compared with community controls (80.22 versus 74.80). On the Brief Symptom
Inventory, pregnant women reported significantly higher
levels of emotional distress on the three global measures and
on the somatization (0.75 versus 0.35), obsessive-compulsive
(0.70 versus 0.48), and hostility (0.59 versus 0.36) subscales
than controls; those changes normalized in the puerperium.
Conclusion: Pregnancy and the puerperium are associated
with significant changes in psychological and physiologic
health status. Documentation of those changes is important
if the Short Form-36 and Brief Symptom Inventory are to be
used in health outcomes research with this population.
(Obstet Gynecol 1999;94:935 41. 1999 by The American
College of Obstetricians and Gynecologists.)

From the Departments of Psychology and Obstetrics and Gynecology,

London Health Sciences Centre and The University of Western Ontario,
London, Ontario, and the Addiction Foundation of Manitoba, Branden,
Manitoba, Canada.

VOL. 94, NO. 6, DECEMBER 1999

Self-administered surveys have become important tools

for evaluating the quality of health care. Traditionally,
measures of health have focused on specific diseases or
chronic health problems with emphasis on evaluation
of disease-related symptoms. Long used to study pregnancy, this approach has served as a basis for teaching
health professionals to differentiate between normal
physiologic changes of pregnancy and disease states.
Traditional health outcome measures of importance are
maternal and perinatal morbidity and mortality rates.
Those measures have been important in understanding
and planning maternal-infant care by governments and
health care institutions.
During the past 10 years, self-administered general
and psychological health questionnaires that measure
patients perceptions of their own health or recognition
of specific behaviors or emotions have become more
prevalent research tools. These tools describe health in
broad terms such as prolongation of life, freedom from
physical or emotional distress or limitations, and prevention of disability. Generic health outcome measures
are not specific to any particular disease and are ideal
for studying pregnancy because most women view
pregnancy as a normal event. Families in developed
countries generally expect positive outcomes of pregnancy. Morbidity or death from pregnancy are unexpected outcomes that health care providers hope to
prevent. Because health care providers must meet the
expectations of patients as consumers, they must ensure
that the outcomes of interest are clearly important to
patients and are measures of quality of care.
In pregnancy and the puerperium, normative qualityof-life information and psychosocial data, using wellvalidated survey instruments with known psychometric properties, are lacking. Much of the work to date
reports on psychological disease states such as postpartum depression and, to a lesser degree, psychosis and
anxiety.15 Quality-of-life assessment in pregnancy has

0029-7844/99/$20.00
PII S0029-7844(99)00439-1

935

been reported for specific disease states such as human

immunodeficiency virus (HIV),6 but little is known
about the effect of usual pregnancy on quality of life,
general health, or psychological symptoms status. A
MEDLINE search of English language literature from
1966 to 1999 using the terms pregnancy and BSI or
pregnancy and SF-36 found only two publications
that explored psychological distress and quality of life
in uncomplicated pregnancies.7,8 Hueston and KasikMiller7 monitored 125 healthy white women throughout pregnancy using the Short Form-36. They found
that functional status declined during pregnancy with
regard to physical functioning, role limitations resulting
from physical problems, and bodily pain scales. They
concluded that health-related functional status during
pregnancy changed only for physical measures of
health. Coble et al8 monitored psychological symptom
status of volunteers from 12 weeks gestation to 8
months postpartum. They found higher prevalence of
symptoms during pregnancy, but their small sample
did not allow for creating norms on any of the instruments used, including the Brief Symptom Inventory.
The purpose of our study was to identify normative
psychological and general health status in pregnant
women in the third trimester and the puerperium. We
chose two questionnaires, the Brief Symptom Inventory
by Derogatis9 and the Short Form-36 by Ware.10 We
compared results in an unselected population of pregnant women who sought hospital-based obstetric care
with those of nonpregnant women in the general population.

Methods
From September of 1996 to July of 1997, a sample of
pregnant women presenting for obstetric services
agreed to complete the Brief Symptom Inventory and
the Short Form-36 in physicians waiting rooms.
Women were recruited consecutively and were excluded if they could not read English or were not in the
third trimester of pregnancy. Five hundred surveys
were printed, which were distributed to physicians
offices by a study coordinator. The women were given a
second, identical survey in a stamped addressed envelope upon discharge after their infants birth. They were
asked to complete the survey and return it by mail
before their first postpartum visit, usually 6 weeks
postpartum. To improve survey return rates, women
were contacted by phone if follow-up surveys were not
completed.
All subjects delivered in the same teaching hospital,
classified as a level II center, with a perinatal mortality
rate between 7.5 and 7.7 per 1000 births per year. At the
center there are approximately 2300 births more than 32

936 Otchet et al

Psychological Symptom Status

weeks gestation per year. Births before 32 weeks

gestation are referred to the high-risk center located in
the same city. Women who present for delivery without
prenatal care are rare because of socialized health care.
Seventy-five percent of births are attended by specialist
obstetrician-gynecologists, whereas approximately 20%
are attended by family physicians and less than 5% by
midwives.
The Brief Symptom Inventory and Short Form-36
were scored by prescribed procedures outlined in their
respective manuals.9,10 Means and standard deviations
on subscales of the measures were computed using the
Statistical Packages for Social Sciences (SPSS, Inc., Chicago, IL). Responses of the pregnant women were
compared with published responses of community
samples of women9,10 using t tests. Paired-sample t tests
were used to compare the means between antepartum
and postpartum survey results. For all tests, statistical
significance was determined at P .01.
The Brief Symptom Inventory and Short Form-36 are
self-report instruments that are brief, economical, easily
administered, and easily scored. They have been used
extensively in clinical and research settings, including
for screening and triage. Both have been well validated
for use with medical and community samples.
The Short Form-36 is a general health survey designed to detect changes in health status from the
patients perspective. It has shown reliability and validity.10 The Short Form-36 captures the following eight
health concepts: physical functioning, including presence and extent of physical limitations; role limitations
resulting from poor physical health, including limitations, reduction in duration, and difficulties performing
activities; role limitations resulting from poor mental
health, including limitations, reduction in duration, and
difficulties performing activities; bodily pain, including
intensity of bodily pain or discomfort and interference
with normal activities; general health; vitality, including energy level and fatigue; social functioning, including quantity and quality of social activities with others;
and mental health, including items from the following
four mental health dimensions: anxiety, depression,
loss of behavioral or emotional control, and psychological well being. Higher scores are associated with better
function.
The normative community sample for the Short
Form-36, reported in Wares Short Form-36 manual,
consisted of 358 women from 25 to 34 years old, a
subsample of a group selected to represent the characteristics of the United States population based on factors
such as age, gender, race, income, employment status,
and region. The specific characteristics of the subsample
are not published.
The Brief Symptom Inventory is a 53-item scale

Obstetrics & Gynecology

Table 1. Short Form-36 Results in the Third Trimester of Pregnancy

Pregnant sample

Community sample

Characteristic

Mean

Standard
deviation

Sample
size*

Mean

Standard
deviation

Sample
size

Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems

51.86
77.27
74.34
62.91
74.00
47.24
79.78

17.61
16.91
16.00
24.06
22.56
18.29
33.80

391
382
382
370
388
373
389

79.61
74.80
72.45
89.12
84.06
58.04
82.32

20.94
17.24
18.62
18.72
21.66
20.85
31.30

275
275
275
275
275
275
275

18.62
1.83
1.02
14.98
5.75
7.01
0.98

.001
NS
NS
.001
.001
.001
NS

45.00

40.25

385

86.73

27.99

275

14.80

.001

NS not significant.
* Unequal sample sizes reflect missing data.

designed to measure current, point-in-time, psychological symptom status. Subjects are asked to rate how
much they have had symptoms in the past 7 days
including today on five-point Likert scales that range
from not at all to extremely. The inventory is
divided into the following nine symptom dimensions:
somatization, ie, distress arising from perceptions of
bodily dysfunction; obsessive-compulsive thoughts, impulses, and actions that are experienced as unremitting
and irresistible; interpersonal sensitivity, ie, feelings of
personal inadequacy and inferiority; depression, including the representative range of indicators of clinical
depression; anxiety, ie, nervousness, tension, panic attacks, feelings of terror, apprehension, and some somatic correlates of anxiety; hostility, ie, thoughts, feelings, or actions characteristic of anger; phobic anxiety,
ie, fears that are irrational and disproportionate to the
stimulus and lead to avoidance or escape behavior;
paranoid ideation, ie, hostility, suspiciousness, grandiosity, fear of loss of autonomy, and delusions; and
psychoticism from mild interpersonal alienation to dramatic psychosis. The inventory also contains three
global indices of present level of distress. Higher scores
indicate greater distress.
The normative community sample for the Brief
Symptom Inventory, reported in the Brief Symptom
Inventory manual, consisted of 358 women with a mean
age of 46 years. Eleven percent were black, 86% were
white, and 3% were of other races. Twenty-five percent
were single, 60% were married, and 15% had another
marital status.

Results
Three hundred ninety-three women agreed to participate in the study and completed the first part of the
survey. Of those, 253 returned the second part of the

VOL. 94, NO. 6, DECEMBER 1999

survey. No significant differences (at the .01 level) were

found on any of the subscales of the Brief Symptom
Inventory or Short Form-36 between those who completed and those who did not complete the survey.
The mean age of the pregnant sample was 28 years 9
months. Fifty-two percent of the sample was parous.
The mean ( standard deviation [SD]) years of education was 14 ( 2.3). Seventy-six percent of the sample
was married, and 17.5% was living by common law
marriage, 4.7% were single, and 1.8% were divorced or
separated. Of the 80% who answered questions about
racial identity, 90.6% were white, 2.6% were Native
American, 1.9% were Middle Eastern, 1.6% were black,
1.3% were Asian, 1.3% were South or Latin American,
and 0.6% were of mixed racial identity.
With regard to the health status of the sample who
completed both questionnaires, 15% reported prior major medical problems, whereas 85% reported no prior
major medical problems. When asked about any health
problems that made their pregnancies high risk, 14% of
the sample indicated that their health status made their
pregnancies high risk, whereas 86% indicated they had
no health problems that made their pregnancies high
risk. Twenty-two percent of the women had cesarean
deliveries.
On review of completeness of both surveys, one
question on the vitality scale on the Short Form-36 was
often left unanswered. Approximately 4.5% of women
did not answer the question, Did you feel full of pep?
in the antepartum survey, and 3.6% of women left the
question blank when surveyed postpartum.
Means, standard deviations, sample sizes, t test comparisons with the community sample, and significance
values for the Short Form-36 and Brief Symptom Inventory in the pregnant sample are presented in Tables 1
and 2, respectively. Results of several subscales of the
Short Form-36 significantly differed from those of the

Otchet et al

Psychological Symptom Status

937

Table 2. Brief Symptom Inventory Results in the Third Trimester of Pregnancy

Pregnant sample
Symptom

Sample
size*

0.75
0.70
0.55
0.41
0.50
0.59
0.23
0.35
0.23
0.51
1.45

0.63
0.72
0.71
0.61
0.59
0.59
0.44
0.56
0.46
0.49
0.45

388
388
387
388
388
387
387
388
388
388
378

16.74

11.16

384

Mean

Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global symptom index
Positive symptom
distress index
Positive symptom total

Community sample

Standard
deviation

Standard
deviation

Sample
size

0.35
0.48
0.40
0.36
0.44
0.36
0.22
0.35
0.17
0.35
1.32

0.46
0.54
0.55
0.56
0.54
0.45
0.44
0.49
0.34
0.37
0.43

358
358
358
358
358
358
358
358
358
358
358

10.0
4.7
3.2
1.17
1.45
5.94
0.31
0.00
2.01
5.0
4.0

.001
.001
NS
NS
NS
.001
NS
NS
NS
.001
.001

12.86

9.97

358

4.98

.001

Mean

NS not significant.
* Unequal sample sizes reflect missing data.

community counterparts. Pregnant women had significantly lower scores, indicating a poorer level of function, on the following subscales: bodily pain, physical
functioning, social functioning, vitality, and functional
limitations resulting from physical health problems.
Results of the Brief Symptom Inventory were also
remarkably different compared with the communitybased sample. Pregnant women showed significantly
higher levels of emotional distress (higher scores) on
the following Brief Symptom Inventory global measures: global symptom index, positive symptom distress index, and positive symptom total. Also significantly greater emotional distress was noted on the
somatization, obsessive-compulsive, and hostility subscales compared with the community sample.
Means, standard deviations, sample sizes, t test comparison with the community sample, and significance
values for the Short Form-36 completed during the

puerperium are shown in Table 3. On the Short Form36, significant differences persisted between postpartum women and the community sample for bodily pain,
social functioning, vitality, physical role limitations,
and physical functioning scales. The postpartum sample indicated a poorer level of functioning compared
with community controls. In contrast to the antepartum
findings, scores on the general health scale for women
in the puerperium were significantly greater than scores
in the community controls, indicating improved functioning of women in the puerperium. In marked contrast to the same population in the third trimester, no
significant differences were found between the postpartum sample and the community sample in any of the
mean global scale scores or the means on the individual
subscales of the Brief Symptom Inventory (data not
shown).
Paired t tests were used to compare responses on the

Table 3. Short Form-36 Results in the Puerperium

Puerperium sample

Community sample

Characteristic

Mean

Standard
deviation

Sample
size*

Mean

Standard
deviation

Sample
size

Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems

48.92
80.22
75.52
62.48
68.38
45.10
74.33

21.19
16.51
15.48
25.61
24.65
19.02
37.58

253
252
251
244
251
244
248

79.61
74.80
72.45
89.12
84.06
58.04
82.32

20.94
17.24
18.62
18.72
21.66
20.85
31.30

275
275
275
275
275
275
275

18.49
3.69
1.36
6.96
7.76
7.35
2.65

.001
.001
NS
.001
.001
.001
NS

42.97

40.98

249

86.73

27.99

275

14.35

.001

NS not significant.
* Unequal sample sizes reflect missing data.

938 Otchet et al

Psychological Symptom Status

Obstetrics & Gynecology

Table 4. Paired Comparisons on the Short Form-36 Between the Third Trimester and the Puerperium
Mean value

Standard
deviation of
paired difference

Characteristic

Pregnancy

Puerperium

Sample
size*

Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems

52.24
78.30
75.72
63.89
74.50
46.13
81.38

48.92
80.31
75.70
62.19
68.40
44.98
74.22

253
247
244
235
248
238
247

24.38
13.87
15.02
29.43
25.67
15.90
39.28

2.16
2.29
0.02
0.89
3.74
1.12
2.86

NS
NS
NS
NS
.001
NS
.005

44.56

42.84

248

47.93

0.56

NS

NS not significant.
* Unequal sample sizes reflect missing data.

Short Form-36 before and after delivery (Table 4). There

was a statistically significant reduction in the level of
social functioning in the puerperium. There was also a
significant reduction in functional limitations resulting
from emotional problems in the puerperium compared
with the third trimester of pregnancy.
Paired t tests were used to compare mean scores on
the nine symptom dimensions and three global indices
of distress of the Brief Symptom Inventory for women
who completed questionnaires in the third trimester
and the puerperium (Table 5). Significant reductions in
level of emotional distress were noted in the puerperium on the somatization and hostility subscales and on
the three global indices of the Brief Symptom Inventory
(global symptom index, positive symptom distress index, and positive symptom total).

Discussion
This study established a set of norms for the Short
Form-36 and the Brief Symptom Inventory in a large

sample of pregnant women during the third trimester

and the puerperium. Pregnant women in the third
trimester and puerperium significantly differed from
the community sample on several dimensions of quality
of life, showing that women in late pregnancy and the
puerperium have poorer qualities of life than nonpregnant women. Consistent with the findings of Hueston et
al,7 pregnant women reported more bodily pain, poorer
physical functioning, and more functional limitations
resulting from physical health problems. Pregnant
women in the present study reported poorer social
functioning and lower vitality than the community
sample.
When women in the puerperium were compared
with the community controls, results were the same
except that they had significantly higher scores on the
overall general health scale compared with community
controls. The reasons for that are not entirely clear. The
general health questions on the Short Form-36 deal
mostly with perceptions of ones health individually
and in relation to others. It is possible that after a

Table 5. Paired Comparisons on the Brief Symptom Inventory Between the Third Trimester and the Puerperium
Mean value
Symptom

Pregnancy

Puerperium

Sample
size*

Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global symptom index
Positive symptom distress index
Positive symptom total

0.71
0.71
0.52
0.37
0.48
0.55
0.22
0.32
0.20
0.48
1.43
16.2

0.44
0.63
0.46
0.36
0.41
0.44
0.18
0.28
0.21
0.39
1.34
13.4

248
248
244
248
248
248
248
248
248
248
219
243

Standard
deviation of
paired difference

0.55
0.60
0.54
0.49
0.48
0.43
0.30
0.46
0.41
0.33
0.37
8.38

7.76
2.18
1.84
0.29
2.38
3.98
2.16
1.37
0.30
4.51
3.33
5.13

.001
NS
NS
NS
NS
.001
NS
NS
NS
.001
.002
.001

NS not significant.
* Unequal sample sizes reflect missing data.

VOL. 94, NO. 6, DECEMBER 1999

Otchet et al

Psychological Symptom Status

939

successful delivery women have a more positive perception of their overall health status, despite their
reported physical, social, and emotional limitations.
This finding might be founded in the belief that giving
birth is often viewed as evidence of good health. The
significant decrease in social functioning after delivery
and significantly lower scores in the puerperium for
functional limitations resulting from emotional distress
might indicate additional demands that newborn infants place on mothers or couples.
On the Short Form-36, the reduction in the dimensions of health measured might be resulting from the
known physiologic changes in pregnancy and the puerperium, including factors associated with recovering
from the birthing process and care of newborns. Further
support for this conclusion comes from the study by
Hueston et al7 in which repeated assessments using the
Short Form-36 were made in women throughout their
pregnancies. They found that physical health status
(bodily pain, physical functioning, and role limitations
resulting from physical problems) negatively correlated
with gestational age, suggesting that pregnancy was the
cause of the changes. Other studies showed that recovery of physical and social functioning after delivery
requires longer than 6 weeks, which is often presumed
to constitute the puerperium. Tulman et al11,12 and Mike
et al13 found that women still reported considerable
limitations in their abilities to function at work and at
home even up to 6 months postpartum.
Pregnant women reported higher levels of psychological distress compared with controls, including
symptoms of obsessive-compulsive behavior and hostility along with the global symptom indices. The same
sample of women in the puerperium did not differ
significantly from controls on any psychological symptom measures, which was further supported by a significant reduction (less distress) during the puerperium
in the three global scales of the Brief Symptom Inventory and the hostility and somatization subscales.
The normalization of the psychological symptom
scales on the Brief Symptom Inventory in the puerperium suggested that there are psychological changes
associated specifically with pregnancy. The results on
the somatization scale might be confounded by symptoms commonly experienced during pregnancy. The
somatization scale asks questions about nausea, faintness, shortness of breath, numbness, tingling, hot or
cold spells, and pains in the heart or chest. It is more
difficult to explain the increase in hostility and obsessive-compulsive symptoms. Changes on the Brief
Symptom Inventory did not persist into the puerperium, unlike the other physical and social adaptations
addressed by the Short Form-36. We were surprised
that women in our sample displayed significantly more

940 Otchet et al

Psychological Symptom Status

symptoms of psychological distress during pregnancy

than during the puerperium, given the attention in the
literature to postpartum depression. Neither survey
showed any notable change in depressive symptoms in
the study sample during third trimester or in the
puerperium compared with each other or the controls.
There appear to be some limitations to the Short
Form-36 when used specifically in pregnant populations. It appears to capture changes in physical and
social functioning associated with pregnancy, but based
on our experience it might be necessary to reword the
vitality question containing the term pep because
3.5 4.5% of the subjects in our study did not answer
that question. The Brief Symptom Inventory appears to
be more comprehensive than the Short Form-36 for
detecting changes in psychological health status in
pregnancy. The Short Form-36 mental health scale primarily inquires about symptoms of anxiety and depression, and no significant differences were found using
this scale between subjects in late pregnancy or the
puerperium and controls. The Brief Symptom Inventory
addresses many other types of symptoms and behaviors besides anxiety and depression. The results of the
BSI found that pregnant women reported more symptoms of psychological distress, including hostility and
somatization, compared with their responses in the
puerperium.
Our results should be interpreted with caution because of several sources of bias. The difference in age
between the pregnant sample and controls, particularly
on the Brief Symptom Inventory, introduced potential
age bias. The community samples were recruited in the
United States, whereas the pregnant sample was recruited in Canada, which could also cause bias. For
example, the samples differed in distribution of races
consistent with each countrys demographics. There
was also opportunity for bias between pregnant subjects who completed the study and those who did not
because only 64% gave postpartum data. Although
completers and noncompleters did not differ on any of
the subscales of the Brief Symptom Inventory or Short
Form-36 (at the .01 level), there might still be differences
that affected results.
What do the findings of this study mean in relation to
maternal and child care? Street et al14 examined the
utility of the Short Form-36 in 58 pregnant women,
specifically whether they felt they benefitted when
physicians inquired about various aspects of health
status in the survey. The women indicated that they
preferred to be asked about their health in general, and
particularly about their physical health. They were
much less interested in being asked about their psychosocial health. When health status information from the
Short Form-36 was provided to obstetric residents be-

Obstetrics & Gynecology

fore the patient visit, it did not alter the physicians

depth and scope of questioning about that information.
Physicians should be aware of aspects of psychoemotional health addressed by the Short Form-36 and be
prepared to explore them with receptive patients.
The birth experience is well suited for contemporary
study using newer self-reporting measures of general
health status and psychologicalal health because it is
more often thought of as a consequence of health than
a disease. However, those measures can never replace
appropriate maternal and fetal assessment, which requires more traditional and technologic forms of health
assessment.

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Address reprint requests to:

Felicia Otchet, PhD

Department of Obstetrics and Gynecology
The London Health Sciences Centre
800 Commissioners Road E.
London, ON N6A 4G5
Canada
E-mail: felicia.otchet@lhsc.on.ca

Received February 19, 1999.

Received in revised form May 24, 1999.
Accepted June 10, 1999.

Copyright 1999 by The American College of Obstetricians and

Gynecologists. Published by Elsevier Science Inc.

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