Mental and Physical Distress and High-Risk

Behaviors Among Reproductive-Age Women

Indu B. Ahluwalia, MPH, PhD, Karin A. Mack, PhD, and Ali Mokdad, PhD
OBJECTIVE: To examine the prevalence of mental and physical distress indicators among women of reproductive age
and the association of these indicators with cigarette smoking and alcohol use, by pregnancy status.
METHODS: The Behavioral Risk Factor Surveillance System
data for several years were aggregated across states and
weighted for this analysis. Seven measures of self-reported
mental and physical distress and general health were examined along with demographic variables.
RESULTS: Overall, 6.7% (95% confidence interval CI 6.5
6.9) of women reported frequent physical distress, 12.3%
(95% CI 12.0 12.6) reported frequent mental distress, 9.9%
(95% CI 9.4 10.4) reported frequent depression, 18.4%
(95% CI 17.8 19.1) reported feeling anxious, and 34.3%
(95% CI 33.535.1) reported that they frequently did not get
enough rest. At the time of the survey 4.6% of the women
were pregnant. Pregnant women were less likely than
nonpregnant women to report frequent mental distress.
Although there was attenuation of cigarette smoking and
alcohol use during pregnancy, those with mental and physical distress were more likely to consume cigarettes and
alcohol than were those without such experiences.
CONCLUSION: High proportions of reproductive-age women
report frequent mental and physical distress. Women experiencing mental and physical distress were more likely to
report consuming cigarettes and alcohol than women without such experiences. (Obstet Gynecol 2004;104:477 83.
2004 by The American College of Obstetricians and
Gynecologists.)
LEVEL OF EVIDENCE: III

Research shows that 20% to 25% of women will experience depression during their life and that depression is
common among women of child bearing age.1 6 Depression is one of the most common reasons for a nonobstetric hospital stay among women 18 to 44 years old.7
Gender differences in rates of depression are generally
not observed until after puberty and appear to decrease
From the Division of Adult and Community Health, National Center for Chronic
Disease Prevention and Health Promotion, and Division of Unintentional Injury,
National Center for Injury Prevention and Control, Centers for Disease Control and
Prevention, Atlanta, Georgia.
VOL. 104, NO. 3, SEPTEMBER 2004
2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.

after menopause; hormones, along with stress and other

predisposing biologic, social, and psychosocial factors,
may play a role in experiences with depression.1,2,5 8
Women experience higher prevalence of both mental
distress (eg, depression, mood disorders) and physical
distress (eg, activity limitation) than men, and the prevalence of these is even higher for women of reproductive
age.8 13
Socioeconomic factors such as marital status, education, and family history of mood disorders are linked
with health-related behaviors and health outcomes.14,15
Studies have shown that poor mental and physical health
is related to participation in high-risk behaviors of cigarette smoking and alcohol and illicit drug use and that
these factors in turn are associated with increased mortality and morbidity.3,4,16 23 Furthermore, mental and
physical health problems during pregnancy are linked to
poor attendance at antenatal clinics, continuation of
high-risk behaviors (eg, cigarette smoking), poor social
functioning, preeclampsia, low birth weight, preterm
births, and problems with social and emotional development among children.24 27 Two recently published studies focused on the high prevalence of depression among
pregnant women and the lack of attention to systematic
screenings and counseling of women during this critical
period.28,29 In fact, some researchers and practitioners
have suggested integrating behavioral healthcare with
routine practice of obstetrics and gynecology, because
such practitioners are often the primary care providers
for reproductive-age women.30 The purpose of this
study was to examine the distribution of mental and
physical health distress measured by the Health Related
Quality of Life indicators and the association between
these indicators and cigarette and alcohol consumption
among reproductive-age women. We selected women of
reproductive age for several reasons, including higher
rates of mental and physical distress, life-stage, and prevention opportunities available to them at this time. We
stratified our analysis by pregnancy status because many
women change their own behaviors while others are
advised to avoid high-risk behaviors.

0029-7844/04/$30.00
doi:10.1097/01.AOG.0000137920.58741.26

477

MATERIALS AND METHODS

We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1998, 2000, and 2001.
Behavioral Risk Factor Surveillance System data from
1999 were not included because the Health Related
Quality of Life module was not part of the 1999 Behavioral Risk Factor Surveillance System survey. The Behavioral Risk Factor Surveillance System is an ongoing,
state-based, random-digit-dialed telephone survey of the
noninstitutionalized US population 18 years of age or
older. It is used to monitor health-related behaviors and
characteristics in all 50 states, the District of Columbia,
and the 3 US territories of Puerto Rico, US Virgin
Islands, and Guam. The Behavioral Risk Factor Surveillance System survey included a core set of 4 Health
Related Quality of Life measures, collected by all states,
and an optional rotating module, selected by certain
states, with additional Health Related Quality of Life
questions that were administered by 13 states in 1998, 23
states in 2000, and 13 states in 2001. Response rates
varied by state, the median response rates were 59.1%
for 1998; 48.9% for 2000; and 51.1% for 2001. Of the
156,428 female Behavioral Risk Factor Surveillance System participants of reproductive age, 147,532 (94%) had
information on pregnancy status available. The percentage excluded for missing data ranged from less than
0.2% for womens age to 11% for income. Behavioral
Risk Factor Surveillance System data quality is optimal
when compared with other national surveys, data are
shown to be reliable and valid, and additional information is available online at http://www.cdc.gov/Behavioral
Risk Factor Surveillance System.31 This study was approved by the Institutional Review Board of the Centers
for Disease Control and Prevention.
We used both core and module Health Related Quality of Life indicators to assess the nature and extent of
self-reported physical and mental distress among women
of reproductive age (Box). We used general self-reported
health status (n 147,373), recent physical health (n
146,272), recent mental health (n 145,838), and recent
activity limitation due to poor physical or mental health
(n 88,101). Health Related Quality of Life indicators
for recent depression (n 40,638), stress and anxiety
(n 40,502), and lack of rest (n 40,725) were assessed
from the optional modules. These Health Related Quality of Life measures have been validated among several
populations in the United States and other countries.32
Measures in this study were dichotomized by using 14 or
more days as the cutoff value for determining the chronic
presence of mental and physical distress.9 13

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Mental and Physical Distress Among Women

Questions Used to Assess the Health Related

Quality of Life Measures, Behavioral Risk Factor
Surveillance System
Health Related Quality of Life Questions From the Core
Module
General Health Status: In general, would you
say your health is excellent, very good, good,
fair, or poor?
Physical Health: Thinking about your physical
health, which includes physical illness and injury,
for how many days during the past 30 days was
your physical health not good?
Mental Health: Thinking about your mental
health, which includes stress, depression, and
problems with emotions, for how many days
during the past 30 days was your mental health
not good?
Activity Limitation: During the past 30 days, for
about how many days did poor physical or mental health keep you from doing usual activities,
such as self care, work, or recreation?
Health Related Quality of Life Questions From the Optional
Module*
Depression: During the past 30 days, for about
how many days have you felt sad, blue, or depressed?
Stress and Anxiety: During the past 30 days, for
about how many days have you felt worried,
tense, or anxious?
Lack of Rest: During the past 30 days, for about
how many days you felt that you did not get
enough rest or sleep?
*A selected set of states used the optional module
with these questions.
We considered a number of demographic variables in
the analysis including womens age, race, education,
marital status, whether they had any children, income,
and health insurance coverage. The 2 health-risk behaviors examined were cigarette smoking and alcohol use.
These behaviors were examined because pregnant
women are advised to refrain from smoking and using
any alcohol and because these have been linked to
mental distress and adverse pregnancy outcomes.

OBSTETRICS & GYNECOLOGY

Table 1. Demographic Characteristics of Reproductive-Age Women by Pregnancy Status, Behavioral Risk Factor Surveillance System
Demographic characteristics
Age in years
1824
2529
3034
3539
4044
Race or ethnicity
Black
Hispanic
Other
White
Education
High school
High school
Some college
College
Marital status
Single
Divorced or separated or widowed
Couple
Married
Have children
Yes
No
Income level in dollars
15,000
15,00024,9999
25,00049,999
50,00074,999
75,000
Health Insurance coverage
Yes
No

Overall (N 147,532)

Pregnant (n 6,208)

Not pregnant (n 141,324)

24.3 (23.924.7)
17.4 (17.117.7)
19.0 (18.619.3)
20.4 (20.120.7)
19.0 (18.719.3)

32.5 (30.534.6)
27.9 (26.229.7)
25.3 (23.626.9)
11.7 (10.412.9)
2.6 (1.93.2)

(23.424.3)
16.9 (16.517.2)
18.7 (18.318.9)
20.8 (20.521.2)
19.8 (19.520.2)

11.4 (11.111.7)
15.8 (15.316.3)
5.5 (5.25.7)
67.3 (66.767.8)

10.8 (9.512.0)
17.3 (15.619.1)
6.2 (4.97.5)
65.7 (36.667.8)

11.4 (11.111.7)
15.7 (15.216.2)
5.5 (5.25.6)
67.4 (66.967.9)

10.3 (9.910.6)
29.7 (29.330.1)
30.9 (30.531.3)
29.1 (28.729.5)

12.9 (11.414.4)
29.3 (27.331.2)
27.6 (25.829.4)
30.2 (28.531.9)

10.2 (9.810.5)
29.7 (29.330.1)
31.1 (30.731.5)
29.0 (28.629.4)

27.8 (27.428.2)
12.2 (11.912.5)
4.8 (4.65.0)
55.2 (54.855.6)

17.1 (15.418.7)
5.4 (4.26.6)
6.7 (5.57.8)
70.9 (68.972.9)

28.3 (27.928.7)
12.6 (12.312.8)
4.7 (4.44.9)
54.5 (54.054.9)

(65.666.4)
34.0 (33.634.4)

66.7 (64.868.6)
33.3 (31.435.2)

65.9 (65.666.4)
34.1 (33.634.4)

12.0 (11.612.4)
18.9 (18.519.3)
35.4 (34.935.9)
17.4 (17.117.7)
16.2 (15.916.6)

10.9 (9.512.3)
20.9 (19.122.7)
35.0 (32.937.1)
16.3 (14.817.8)
16.9 (15.318.4)

12.1 (11.712.4)
18.9 (18.519.2)
35.4 (34.935.9)
17.4 (17.017.8)
16.3 (15.916.6)

82.0 (81.682.4)
18.0 (17.618.4)

88.3 (86.989.7)
11.7 (10.313.1)

81.7 (81.382.1)
18.3 (17.918.7)

Values are percentage and (95% confidence interval). Percentages may not add to 100 due to rounding.

Women were considered to have a history of cigarette

smoking if they reported smoking at least 100 cigarettes
in their lifetime and to be current smokers if they reported smoking every day or some days. Alcohol
use was defined as having had at least one drink of an
alcoholic beverage during the past month. Binge drinking was defined as having consumed 5 or more drinks on
one occasion in the previous month. We used software
for survey data analysis (SUDAAN, Research Triangle
Institute, Research Triangle Park, NC) to account for the
complex sample design and to generate prevalence estimates and standard errors and to perform multivariate
analyses.
RESULTS
The overall demographic characteristics of the population indicate that more than 50% of the women were
between 30 to 44 years of age; 67.3% of the population
studied was white, 11.4% black, 15.8% Hispanic, and

VOL. 104, NO. 3, SEPTEMBER 2004

5.5% were categorized as other. The majority were married, had children, had incomes of $25,000 or above, and
reported having health insurance coverage (Table 1).
Overall, 4.6% (6,208) of the women were pregnant at the
time of the interview. The demographic profile of pregnant women was quite similar to that of nonpregnant
women on race, education level, and income. However, a
higher proportion of pregnant women were younger, married, and reported having health insurance (Table 1).
The majority of women reported that their general
health was excellent (25.8%; 95% confidence interval
CI 24.4 26.2) or very good (36.4%; 95% CI 36.0
36.8); more than a quarter reported that their health was
good (28.2%; 95% CI 27.6 28.4), and 9.3% (95% CI
9.0 9.6) reported that their health was fair or poor
(Table 2). Overall, 6.7% (95% CI 6.5 6.9) reported
frequent physical distress, 12.3% (95% CI 12.0 12.6)
reported frequent mental distress, and 7.1% (95% CI
6.77.4) reported frequent activity limitation due to poor

Ahluwalia et al

Mental and Physical Distress Among Women

479

Table 2. Health-Related Quality-of-Life and Selected Behavioral Indicators by Pregnancy Status, Behavioral Risk Factor
Surveillance System
Health-related quality-of-life
measures
General health: fair or poor ( 14 days)
Frequent physical distress ( 14 days)
Frequent mental distress ( 14 days)
Frequent activity limitation ( 14 days)
Frequent depression ( 14 days)*
Frequent stress or anxiety ( 14 days)*
Frequent lack of rest ( 14 days)*
Behaviors
Current cigarette smoker
Drank alcohol in past month
Binge drank in past month

Overall (N 147,532)

Pregnant (n 6,208)

Not pregnant (n 141,324)

9.3 (9.09.6)
6.7 (6.56.9)
12.3 (12.012.6)
7.1 (6.77.4)
9.9 (9.410.4)
18.4 (17.819.1)
34.3 (33.535.1)

6.4 (5.47.4)
7.1 (6.28.1)
7.7 (6.78.7)
8.0 (6.69.5)
8.1 (6.010.2)
16.2 (13.718.7)
38.3 (34.841.8)

9.5 (9.29.8)
6.7 (6.56.9)
12.5 (12.312.8)
7.0 (6.77.3)
10.0 (9.410.5)
18.5 (17.819.2)
34.1 (33.334.9)

24.5 (24.124.9)
52.8 (52.153.5)
19.4 (18.820.0)

12.3 (11.013.6)
11.6 (9.813.4)
3.8 (2.45.2)

25.1 (24.725.5)
54.7 (54.055.4)
19.8 (19.220.4)

Values are percentage and (95% confidence interval). Percentages may not add to 100 due to rounding.
* Data on these indicators were collected with an optional module, and only a selected set of states used the module.

mental or physical health (Table 2). Approximately 9.9%

(95% CI 9.4 10.4) reported that they frequently felt sad,
blue, or depressed; 18.4% (95% CI 17.8 19.1) reported
feeling frequently worried, tense, or anxious; and 34.3%
(95% CI 33.535.1) reported that they frequently did not
get enough rest or sleep. Nonpregnant women had a
higher prevalence of cigarette smoking (25.1%; 95% CI
24.725.5) than pregnant women (12.3%; 95% CI 11.0
13.6), as well as higher rates of alcohol use in the past
month (54.7% compared with 11.6%) and binge drinking (19.8% compared with 3.8%).
Among nonpregnant women, those who reported fair
or poor health were more likely (odds ratio OR 1.6;
95% CI 1.4 1.7) to report smoking cigarettes than those
who assessed their general health status to be excellent or
good after adjusting for several demographic characteristics (Table 3). Women with frequent physical distress
were more likely (OR 1.5; 95% CI 1.4 1.7) to smoke
cigarettes than those who did not report such distress.

Those with frequent mental distress (OR 2.0; 95% CI

1.9 2.1), frequent activity limitation (OR 1.6; 95% CI
1.4 1.8), depression (OR 2.2; 95% CI 1.9 2.5), frequent
experiences of stress and anxiety (OR 1.9%; 95% CI
1.72.1), or frequent lack of rest (OR 1.5; 95%CI 1.4
1.7) were more likely to smoke cigarettes than those who
did not report having such problems. The magnitude of
the association was strongest for those who reported
frequent mental distress or depression.
Similarly, among pregnant women, those who reported their general health to be fair or poor were more
likely to report smoking cigarettes (OR 2.4; 95% CI
1.53.8). Pregnant women who reported frequent physical distress (OR 1.7; 95% CI 1.12.6) or mental health
distress (OR 2.5; 95% CI 1.73.7) were more likely to
report smoking cigarettes than pregnant women who did
not report these. It is interesting to note that the magnitude of the association between 3 of the Health Related
Quality of Life indicators (ie, fair or poor health, fre-

Table 3. Association Between Health-Related Quality-of-Life Indicators and Cigarette Smoking Among Pregnant and
Nonpregnant Women, Behavioral Risk Factor Surveillance System
Cigarette smoking
Pregnant
Adjusted OR
(95% CI)*

Crude OR
(95% CI)

Adjusted OR
(95% CI)*

2.2 (1.53.2)
1.7 (1.22.5)
3.2 (2.34.4)
1.8 (1.02.8)
1.8 (1.03.2)
2.1 (1.33.3)
1.8 (1.22.8)

2.4 (1.53.8)
1.7 (1.12.6)
2.5 (1.73.7)
1.5 (0.92.6)
1.3 (0.62.7)
1.3 (0.72.5)
2.0 (1.23.3)

1.7 (1.61.9)
1.8 (1.72.0)
2.5 (2.32.7)
2.0 (1.82.1)
2.6 (2.32.9)
2.3 (2.12.5)
1.6 (1.51.7)

1.6 (1.41.7)
1.5 (1.41.7)
2.0 (1.92.1)
1.6 (1.41.8)
2.2 (1.92.5)
1.9 (1.72.1)
1.5 (1.41.7)

Health-related quality-of-life indicators

General health (fair or poor)
Frequent physical distress ( 14 days)
Frequent mental distress ( 14 days)
Frequent activity limitation ( 14 days)
Frequent depression ( 14 days)
Frequent experience of stress or anxiety ( 14 days)
Frequent lack of rest ( 14 days)

Not pregnant

Crude OR
(95% CI)

OR, odds ratio; CI, confidence interval.

* Adjusted for age, race, education, marital status, income, and whether women had children and health insurance.

Data on these indicators were collected with an optional module, and only a selected set of states used the module.

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OBSTETRICS & GYNECOLOGY

Table 4. Association Between Health-Related Quality-of-Life Indicators and Alcohol Use Among Pregnant and Nonpregnant
Women, Behavioral Risk Factor Surveillance System
Alcohol Use
Pregnant
*Adjusted OR
(95%)

Crude OR
(95% CI)

*Adjusted OR
(95% CI)

1.2 (0.62.2)
0.8 (0.41.7)
1.0 (0.51.8)
1.4 (0.53.6)
1.4 (0.53.6)
1.1 (0.52.5)
0.6 (0.31.0)

1.5 (0.73.1)
0.9 (0.42.0)
1.3 (0.72.5)
1.4 (0.63.5)
2.1 (0.76.6)
1.0 (0.42.4)
0.4 (0.20.8)

0.5 (0.40.5)
0.6 (0.50.7)
1.1 (1.01.2)
0.5 (0.40.6)
1.1 (0.91.2)
1.2 (1.11.4)
1.0 (0.91.1)

0.7 (0.60.7)
0.7 (0.60.8)
1.2 (1.11.3)
0.6 (0.50.7)
1.3 (1.11.5)
1.3 (1.11.5)
1.0 (0.91.1)

Health-related quality-of-life indicators

General health (fair or poor)
Frequent physical distress ( 14 days)
Frequent mental distress ( 14 days)
Frequent activity limitation ( 14 days)
Frequent depression ( 14 days)
Frequent experience of stress or anxiety ( 14 days)
Frequent lack of rest ( 14 days)

Not Pregnant

Crude OR
(95% CI)

OR, odds ratio; CI, confidence interval.

* Adjusted for age, race, education, marital status, income, and whether women had children and health insurance.

Data on these indicators were collected with an optional module, and only a selected set of states used the module.

quent mental distress, and frequent lack of rest) and

smoking was stronger among pregnant than nonpregnant women.
Rates of alcohol use and binge drinking were lower
among pregnant than among nonpregnant women. Because of the small numbers of women in the pregnant
binge drinking category, we could not assess the association between Health Related Quality of Life indicators
and binge drinking. As shown in Table 4, among nonpregnant women those with frequent mental distress
(OR 1.2; 95% CI 1.11.3), frequent depression (OR 1.3;
95% CI 1.11.5), or frequent stress and anxiety (OR 1.3,
95% CI 1.11.5) were more likely to report drinking any
alcohol in the previous month. Most Health Related
Quality of Life measures were not found to be significantly associated with alcohol use among pregnant
women.
DISCUSSION
Our findings show that women of reproductive age
experience substantial amounts of physical and mental
distress, depression, and stress and anxiety, and a high
proportion do not get enough rest or sleep. Moreover,
pregnant women were less likely than nonpregnant
women to report fair or poor health and frequent mental
distress but were more likely to report frequent physical
distress and activity limitation. It is possible that some
differences can be explained by biologic, physical, or
psychological changes related to pregnancy and menstrual cycles.1,2
Our findings are consistent with those from studies in
which women with physical or mental distress were
more likely to engage in high-risk behaviors of cigarette
smoking and substance misuse.3,4,16 23 Although fewer
pregnant women reported smoking cigarettes, those who
were experiencing poor overall health, frequent mental

VOL. 104, NO. 3, SEPTEMBER 2004

distress, or frequent lack of rest were significantly more

likely to report smoking than those without such experiences. In general, the emotional health of reproductiveage women may be associated with engaging in high-risk
behaviors such as substance misuse, which may have
long-term consequences for them and their families.16 27,31
Available encounters between women and providers
should be used to educate women and to focus on
prevention, given that many women in the reproductiveage group could be at risk for having unintended pregnancies and may be experiencing mental or physical
distress and engaging in high-risk behaviors.
Our findings are subject to several limitations. First,
the cross-sectional nature of the data did not allow us to
establish a causal relationship. Second, because the Behavioral Risk Factor Surveillance System is based on
data from a telephone surveys, the results may not be
generalizable to women who do not have telephones or
use only wireless phones. Finally, we were unable to
determine the stage of pregnancy from Behavioral Risk
Factor Surveillance System data. However, we have a
large representative sample of US reproductive-age
women, which enabled us to examine a number of
Health Related Quality of Life indicators and their association with high-risk behaviors.
Our findings highlight the importance of examining
the association between mental and physical distress
measured by Health Related Quality of Life indicators
and high-risk behaviors. Providers should assess the
mental health status of pregnant women during prenatal
care visits and that of nonpregnant women during visits
for routine checkups, family planning visits, and wellchild visits for those with children. These visits provide
opportunities to counsel and support to women engaging
in high-risk behaviors or having difficulty coping with
health conditions or social stressors. Public health agen-

Ahluwalia et al

Mental and Physical Distress Among Women

481

cies, organizations, and primary health care providers

need to develop, implement, and promote integrated
programs for women that take into account mental and
physical health. Interventions that integrate social and
behavioral health along with physical health would be
useful for long-term behavior change that would benefit
not only women but also their families.

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Address reprint requests to: Indu Ahluwalia, MPH, PhD,
Division of Adult and Community Health, Centers for Disease
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K-66, Atlanta, GA 303413724; e-mail: Iahluwalia@cdc.gov.
Received April 12, 2004. Received in revised form June 10, 2004.
Accepted June 17, 2004.

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