The Effect of Paint-by-Numbers Activity on Stress and Prenatal Attachment in High-Risk Pregnancies

Pregnancy, a physiological state, is defined both as a turning point and a developmental crisis . Pregnancy directly affects maternal and child health, and in cases of complications, it can lead to morbidity and mortality, particularly in developing countries . According to data from the World Health Organization (WHO), approximately 830 women worldwide die daily due to preventable pregnancy- and childbirth-related causes, with 99% of all maternal deaths occurring in developing countries, including Turkey (https://www.who.int/news-room/fact-sheets/detail/maternal-mortality).

In Turkey, the 2005 National Maternal Mortality Study reported a maternal mortality rate of 28.5 per 100,000 live births. This study revealed that 49.3% of pregnancy-related deaths and 61.6% of maternal deaths were due to preventable causes Hemorrhage, infection, and preeclampsia/eclampsia are among the leading causes of maternal mortality both in Turkey and globally . This significant issue is included in the Sustainable Development Goals (2016-2030) as a target to reduce global maternal mortality

High-risk pregnancy refers to conditions where maternal, fetal, or neonatal health is partially or entirely at risk . According to the 2013 Turkey Demographic and Health Survey (TNSA), 63% of pregnant women aged 18-34 in Turkey fall into at least one risk category. High-risk pregnancies are associated with various physiological and psychological challenges, negatively impacting maternal, infant, and family health . In addition to posing life-threatening risks, high-risk pregnancies represent a crisis related to fertility . When a pregnancy is high-risk, emotional distress increases due to maternal or fetal complications . Compared to low-risk pregnancies, high-risk pregnant women experience significantly higher stress regarding their own and their baby's health .

Stressors experienced by high-risk pregnant women include receiving a high-risk pregnancy diagnosis, unplanned pregnancy, pregnancy complications, fetal abnormalities, childbirth fears, adolescent pregnancies, marital issues, lack of social support, economic concerns, postpartum problems, and hospitalization . Perceived stress during pregnancy is highly significant for pregnancy outcomes . Pregnancy-related stress has been characterized as a stronger form of stress than general stress due to its ability to trigger heightened physiological arousal . This can have adverse effects, increasing maternal and fetal morbidity and mortality risks . Stress may elevate oxytocin and prostaglandin hormone levels while reducing beta-endorphin and progesterone levels, leading to birth complications or adverse birth outcomes .

Stress during pregnancy has been associated with negative birth outcomes, including preterm labor, spontaneous abortion, neonatal malformations, and growth retardation . Additionally, stress can negatively impact parental attachment to the fetus and newborn . There is a bidirectional relationship between attachment and a woman's psychosocial well-being. Prenatal attachment is influenced by the mother's psychosocial state, and a lack of attachment can negatively affect her mental well-being. Literature suggests a link between prenatal attachment and long-term maternal depression . A study highlighting the potential adverse effects of stress on prenatal attachment in high-risk pregnancies emphasized the importance of supporting prenatal attachment to prevent postpartum issues such as anxiety and depression .

Study Overview

• Status: Not yet recruiting
• Conditions: High-Risk Pregnancies
• Intervention / Treatment: Behavioral: Experimental

Detailed Description

Stress, which has adverse effects even in the postpartum period, is among the modifiable risk factors in high-risk pregnancies. A study published in The Lancet on maternal health reported that at least 40 million women worldwide experience long-term health problems due to childbirth. The study highlighted persistent issues such as anxiety (9-24%), depression (11-17%), and tokophobia (6-15%) months or even years after delivery (Vogel et al., 2024). Many of these conditions are thought to stem from poorly managed stress. A study in Nepal identified stressful life events as contributing factors to postpartum depression symptoms .

Negative pregnancy outcomes not only affect maternal and infant health but also place a significant economic burden on countries. For instance, in the United States, the annual costs associated with preterm birth-including medical care, parental work loss, and specialized education-are estimated at $26 billion. Literature underscores that effective care during pregnancy and childbirth is a crucial preventive factor in identifying risks and preventing complications that could lead to long-term health issues. The International Council of Nurses (ICN) states that nurses play a vital role in educating individuals about what they need to maintain good health.

Hospitalization can create stress for high-risk pregnant women, highlighting the importance of introducing activities that help manage stress during this period. A review of the literature revealed no randomized controlled studies examining the effects of a paint-by-numbers activity on perceived stress and prenatal attachment in hospitalized high-risk pregnant women. This study aims to investigate the effects of a paint-by-numbers activity on stress and prenatal attachment among high-risk pregnant women receiving inpatient care at Erzurum City Hospital. It is anticipated that this study will contribute to reducing stress and enhancing prenatal attachment among women with high-risk pregnancies. Additionally, it is expected to raise awareness among healthcare providers, particularly nurses, about incorporating such activities into their care practices.

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: ŞEVİN POLAT, Research Assistant; Phone Number: +905438082242; Email: sevin.akgun@erzurum.edu.tr
• Study Contact Backup: Name: Ayşe METİN, Assistant Professor (Dr.); Phone Number: +905066812398; Email: ayse.metin@erzurum.edu.tr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Having a high-risk pregnancy
• Being at or beyond the 20th week of pregnancy
• Being hospitalized for at least 4 days for high-risk pregnancy monitoring
• Being open to communication and collaboration
• Being literate in Turkish
• Being over 18 years of age
• Volunteering to participate in the study

Exclusion Criteria:

• Being under 18 years of age

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Group A; Experimental group pregnant women will be asked to paint with numbers of 40x50cm canvases containing mother and baby. Pregnant women will be asked to paint the table according to their own wishes and finish them in about 5 days.	Behavioral: Experimental; Description: After collecting the pre-test data, pregnant women in the experimental group will be informed about the paint-by-numbers activity, and the materials to be used will be introduced. Participants in the experimental group will be asked to choose one of the 40x50 cm paintings. They will then be instructed to complete the painting. Pregnant women will be asked to paint the selected canvas at their convenience over approximately five days. Once the paint-by-numbers activity is completed, participants will be asked to fill out the post-test questionnaires, and final data from the experimental group will be collected, marking the end of the data collection process. After data collection, participants will be gifted their completed paintings, which they can hang in their children's rooms.
No Intervention: Group B; This group will take routine care applications

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Perceived Stress Level	Measured using a validated stress scale (Perceived Stress Scale in High-Risk Pregnancies Based on the Neuman Systems Model (NSM-HRPS). The lowest possible score from NSMt-RGASÖ is 34 and the highest is 170. While the sum of the scores in the sub-dimensions in NSMt-RGASÖ constitutes the stress score in that life area, the sum of the scores of all the items constitutes the total scale score. A high score from the overall scale and the sub-dimensions indicates that the perceived stress in the relevant life area and in general is high.	10-15 Minutes

Collaborators and Investigators

• Sponsor: Erzurum Technical University
• Collaborators: Scientific Research Projects Coordination Unit
• Investigators: Study Director: Ayşe METİN, Assistant Professor (Dr.), Erzurum Technical University Faculty of Health Sciences

Publications and helpful links

General Publications

• Vogel JP, Jung J, Lavin T, Simpson G, Kluwgant D, Abalos E, Diaz V, Downe S, Filippi V, Gallos I, Galadanci H, Katageri G, Homer CSE, Hofmeyr GJ, Liabsuetrakul T, Morhason-Bello IO, Osoti A, Souza JP, Thakar R, Thangaratinam S, Oladapo OT. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. Lancet Glob Health. 2024 Feb;12(2):e317-e330. doi: 10.1016/S2214-109X(23)00454-0. Epub 2023 Dec 6.
• Arslan, S., Okcu, G., Coşkun, A., & Temiz, F. (2019). Women'sperceptıon

Study record dates

Study Major Dates

• Study Start (Estimated): May 15, 2025
• Primary Completion (Estimated): June 15, 2025
• Study Completion (Estimated): September 10, 2025

Study Registration Dates

• First Submitted: February 27, 2025
• First Submitted That Met QC Criteria: April 24, 2025
• First Posted (Actual): May 2, 2025

Study Record Updates

• Last Update Posted (Actual): May 2, 2025
• Last Update Submitted That Met QC Criteria: April 24, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: Randomized controlled trial; Stress management; High-risk pregnancy; Prenatal attachment; Paint-by-numbers activity
• Other Study ID Numbers: 22

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

IPD Plan Description

Confidentiality and Ethical Considerations:

The study involves sensitive health-related data from high-risk pregnant women, making it essential to protect participant privacy.

Ethical guidelines and data protection regulations (e.g., GDPR, HIPAA) restrict the sharing of personally identifiable information.

Institutional and Legal Restrictions:

The data is collected under specific institutional and national regulations that may limit external access.

Institutional Review Board (IRB) or Ethics Committee approval may be required for any data-sharing requests.

Data Security and Misuse Prevention:

To prevent misinterpretation or misuse, raw data will not be publicly available.

Only aggregated results and summary findings will be shared in publications or upon request.

Limited Resources for Data Management:

Providing external access requires additional resources for data anonymization, secure storage, and compliance monitoring.

The research team may not have the capacity to manage extern

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No