Pregnancy is the time in our life representing more than any other
period
the continuation of life and expectations for a brighter future. Any
threat
to the well being of the individual, loss of life in the family or
significant property damage may affect the physical and emotional well
being.
In this manuscript we study few aspects of pregnant women’s behavior and
emotions during and after the earthquake in Adapazari. We found that
initially the patients were very concerned about their own lives but
instinctively they protect their pregnancy by shielding the abdomen with
their hands (53%). The stressful state temporarily affects the fetal
movement’s perception. Nine patients graded their state as being concerned
to extremely concerned in a scale of 1 to 5.
In conclusion, pregnant women are concerned about their own lives as well
as
about their fetus. A Reduction in the perception of fetal movements with a
recovery after several hours is common. The psychological effects of a
life
threatening disaster on pregnant women should be further investigated by
large studies.
Introduction
An earthquake may be a significant threat to life causing casualties
and
loss of property. On August 17, 1999 at 03:04 am, an earthquake of 7.4
Richter scale struck the Marmara region, one of the most
populated
areas of Turkey. The estimated number of casualties was 50,000, of them
20,000 fatalities and another 20,000 people missing.
Pregnancy is the time in our life representing more than any other period
the continuation of life and expectations for a brighter future. Any
threat
to the well being of the Individual, loss of life in the family or
significant property damage may affect the physical and emotional well
being.
The purpose of this manuscript is to look at few aspects of pregnant
women’s
behavior and emotions during and after the earthquake.
Methods
The earthquake significantly damaged the infrastructure of the cities
including that of the health system. Many local medical personnel and
facilities were either hurt, killed, or destroyed, respectively, which
also
made the remaining medical facilities ineffective.
The Israeli defense forces (IDF) have sent a field hospital to the
affected
area in order to assist and substitute for some of the hospital facilities
and services that were significantly damaged in the earthquake. The IDF
field hospital started to function from day 4 to day 14 after the
earthquake
in the city Adapazari - the second most severely damaged city in Turkey.
One of the departments of the field hospital was Obstetrics and
Gynecology.
The services offered by the department were mostly routine primary and
secondary care including operating facilities, which have not been
functioning in the local medical facilities in the first week after the
earthquake. 123 patients were treated at the obstetrics and gynecology
department during the 10 days hat the hospital functioned.
A sample of 15 pregnant patients was selected to fill a questionnaire. An
English Turkish translator assisted an obstetrician to obtain the
responses.
Most patients that were requested to fill in the questionnaire complied.
Questionnaire form
____________________________________________________________
Background:
Name:__________ Family name _________ Serial number:________
Total number of pregnancies: __________
Live babies ______ Dead fetuses: _____
Dead children: ____Other diseases___
How anxious would you describe yourself?
1-calm 2- not so calm 3-anxious 4 –very anxious
5-extremely anxious
Are you pregnant now? yes/no How many months?_____
Earthquake:
Where were you during the earthquake?
1) home 2) relatives 3) others
Who was with you during the earthquake?
1) husband 2) children 3)relatives 4) friends
What were you doing during the earthquake?
1) sleeping 2) working 3)other
What was the first thing you did when the earthquake started?
1) freeze 2)pray 3) flee 4) scream 5) hug someone
6) shield yourself
Did you shield the fetus? yes/no
If yes - how did you do that?
1) hands 2) lie 3) bend down 4) hide under an object
What did you do with other family members?
1) took children 2) took husband 3)
took all family 4) took no one
What was the first thing that crossed your mind
during the earthquake?
1)own death 2) death of husband 3) death of children
4) property loss
Medical:
Were you injured? Yes /No
If Yes where?
Head, Chest, abdomen, extremities.
Did you feel reduced fetal movements after the earthquake?
What brought you to the hospital today?
Why have you chosen to come to this hospital?
1) no other choice 2) I was referred here
3) quality of care 4) availability of ultrasound
How concerned are you about the well being of the fetus?
1) not at all 2)mildly 3) concerned 4) very concerned
5) extremely concerned
What role did the earthquake had in these concerns?
1) earthquake not related 2) little correlation
3) related 4) very related 5) extremely related
How anxious are you now?
1-calm 2- not so calm 3-anxious 4 –very anxious
5-extremely anxious
Post medical examination:
Diagnosis (filled by a doctor)____
Did you have an ultrasound examination?
Have you seen the screen during the examination? Yes/No
How do you feel now?
1-calm 2- not so calm 3-anxious 4 –very anxious 5-extremely anxious
If you feel better, what is the most important factor
that affected it?
1) staff 2) ultrasound 3) medications
____________________________________________________________
Results
The earthquake occurred at 03:04 AM and all patients were inside
buildings,
11 were at home three stayed at relative's house and one was admitted to a
hospital at the time of the earthquake. All 15 patients were accompanied
by
family members during the occasion. 13 were with their husbands, five had
other children with them to rescue and six were staying with other
relatives
as well. 14 patients were at sleep and one was awake during quake. The
patients were asked what was the first action they did while the
earthquake
took place. Six patients fled immediately. Five screamed without taking an
immediate response until the quake was over. Three patients started
praying
and a few were hugged by their husbands. No patients looked for an
immediate
shielding for themselves like finding shelter under the beds. 8 out of the
15 (53%) patient shielded their abdomen during the earthquake in order to
reduce chances of trauma to the fetus. The most common method was by
covering the abdomen by hands while other were hugged by husband while
creating a barrier between the falling objects on or near them.
The patients were asked what was the first thing that crossed their
mind
during the earthquake. Most patients thought about the threat to their own
lives. Only one thought first on their children or husband. Two of the
fifteen pregnant women were injured during the earthquake. The injuries
were
mild.
Seven patients (46%) felt a reduction in fetal movements after the
earthquake. The movements were regained the sense fetal movements within a
couple of hours of the earthquake and all fetuses were evaluated
sonographically and score 8 of 8 on the revised manning biophysical score
(1).
At the time of the medical encounter, prior to the ultrasound
examination
was performed 8 of 15 patients scaled their level of concern for the fetal
well being as concerned to extremely concerned. The rest of the patients
were mildly or not concerned. The patient’s self-grading of anxiety was
tested again after the ultrasound test. The women observed the screen
during
the test. The examiner pointed out the fetal heart beat as well as the
fetal
movements. Six patients said that they feel calmer after the test and only
one said she is still extremely anxious. The average anxiety score after
the
test was 1.75 compared with 2.9 before the ultrasound test in a scale of 1
to 5 where 1 is calm and 5 is extremely anxious.
Discussion
A natural disaster has been defined as a disruption of human ecology
that
exceeds the capacity of the individual or community to function normally.
The event is usually very dramatic and in the case of an earthquake is
sudden, short and terrifying. Fear and anxiety are natural responses to
situation in which casualties are claimed and thousands literally lost all
their belongings.
Pregnancy is a special situation in human being `s life and it
represents
the continuation of the individual’s life as well as the next generation
to
come. Pregnancy can be a stressful situation especially when the family
confronts matters of survival, hunger and loss of shelter as well as the
pregnancy itself.
Lately there have been several studies suggesting correlation between
mass
casualties and adverse reproductive outcomes like, stillbirths, serious
developmental disabilities such as cerebral palsy and mental retardation ,
infertility early pregnancy loss (2,3).
On the 2nd of March 1985, 8-9 Richter scale earthquake and a series of
aftershocks took place in Santiago, Chile. The characteristics of over
22,000 births registered in three public hospitals in the same year were
reviewed. A significant increase in the rate of facial clefts was found.
2.01 per 1000 births in contrast to 1.6 per 1000 births in previous years.
The increase was greater in those born in September: 3.8 per 1000 births.
This increase in clefting could be related to the effects of stress
in
mothers induced by the earthquake. The authors have applied and to test
this
hypothesis 13.5-day-old embryos from two inbred mouse strains, A/Sn and
C57BL/10, were subjected to a similar stress using a vibrator cage to
imitate the main shock and the first five replicas of the earthquake. The
same intensity and duration of shock as in the original earthquake were
applied. The results were 19.8% cleft palates in stressed A/Sn mice and no
clefting in C57BL/10. These findings in mice support the stress hypothesis
for the increase in cleft palate observed in humans. The increase in
reabsorbed embryos in both strains also suggests an effect on stress. The
long-term effects of the earthquake on reproductive outcome in the Turkish
population should be examined in future studies.
Nevertheless, the affect of anxiety on pregnancy outcome is
controversial.
Other studies found little association between psychological scores and
physiological stress hormone concentrations. These studies could not
demonstrate a correlation between stress and adverse pregnancy outcome
(4).
A reduction in the average anxiety grading of 2.9 to 1.75 after the
ultrasound examination warrants the use of this tool for both diagnostic
test as well as for patients reassurance.
The limitations of our study are major. The sample size is small
there in no
control group of non-pregnant women or stress levels of pregnant women not
exposed to a natural disaster. The interviews were prepared and performed
by
physicians not trained specifically as behavioral sciences.
On the contrary, this survey is to the best of our knowledge the first to
describe the emotional process pregnant woman go through during and after
the disaster with respect to their own well-being and that of their
pregnancies. The survey showed that initially the patients are very
concerned about their own lives but instinctively they protect their
pregnancy by shielding the abdomen with their hands (53%).
The stressful state temporarily affects the fetal movement’s perception.
It
is not clear whether there is a true temporary reduction whether there is
only reduction of women’s perception. Studies in sheep correlated
increased
catecholamines to increased fetal movements (5). Nine patients graded
their
state as being concerned to extremely concerned in a scale of 1 to 5.
After
the sonographic test ten of the fifteen patients (75%) said that they
would
define their current emotional status as calm up to anxious. Three
patients
felt extremely concerned even after the test. Sonography has been shown to
be a technology that may reassure expecting mothers on one hand while
alarming others depending on the clinical setup. Based on our limited data
on mother’s concerns about their pregnancies, it seems that sonographic
testing of the pregnancies, showing the mothers the screen including fetal
heart beats and fetal movements has a reassuring role as well as a
diagnostic test for better care of pregnant women during mass casualties.
In conclusion, This small survey draws some light at what pregnant
women
feel and do during and several days after an earthquake. Concerns
regarding
their own life followed by worries about the fetal well being are immense.
Reduction in the perception of fetal movements with a recovery after
several
hours is common. Ultrasound demonstration of fetal biophysical score to
both
the health providers as well to the worried mothers is an important tool
for
reassurance.
Acknowledgment
This article is devoted to the 15 new lives that were given birth in
the IDF
field hospital in Adapazari. We wish to express our gratitude to the 102
members of the IDF field hospital and the Turkish volunteers that assisted
us day and night in the care of the people in Adapazari. Specifically in
this survey helped Ms Basak Duru which assisted in the communication
between
our patients and us.
References
1) Manning FA, Platt LD, Sipus L, Antepartum fetal evaluation: The
development of fetal biophysical profile score.Am J Obstet Gynecol 1980;
136:787.
2) Cordero JF, The epidemiology of disasters and adverse reproductive
outcomes: lessons learned. Environ Health Perspect, 1993; 101: 131-6.
3) Montenegro MA, Palomino H, Palomino HM. The influence of
earthquake-induced stress on human facial clefting and its simulation in mice.
Arch
Oral Biol 1995; 40: 33-7.
4) Milad MP, Klock SC, Moses S, Chatterton R. Stress and anxiety do
not
result in pregnancy wastage. Hum Reprod 1998 ; 13: 2296-300.
5) Boddy K, Dawes GS, Robinson JS:A 24 –hour rhythm in the fetus:
Foetal and
neonatal physiology. Proceedings of Sir Joseph Barecroft Centenary
Symposium. Cambridge, July 25, 1972, London, Cambridge University Press,
1973.
Rapid Response:
Anxiety and fears of pregnant women - Earthquake, Turkey, 1999
Anxiety and fears of pregnant women - Earthquake, Turkey, 1999
David Mankuta MD, Yaron Bar-Dayan MD , Adrian Rachstein MD, Pinhas
Halperin
MD, Boaz Rosen MD , David Morgenstern, Carlos Gruzman MD, Giora
Martonovits
MD, Arieh Eldad MD, Paul Benedek MD,
Keywords: Earthquake, Anxiety, Fetal body movements, field hospital,
Ultrasonography.
Address of correspondence: Dr. David Mankuta,
Head of Obstetrics and Gynecology,
IDF Field Hospital, Adapazari,
2 Harduf Street, Lehavim, Israel
POB 162 Lehavim, Zip 85338
Phone/Fax: 972-7-6510093
E-mail: mankuta@excite.com
Abstract
Pregnancy is the time in our life representing more than any other
period
the continuation of life and expectations for a brighter future. Any
threat
to the well being of the individual, loss of life in the family or
significant property damage may affect the physical and emotional well
being.
In this manuscript we study few aspects of pregnant women’s behavior and
emotions during and after the earthquake in Adapazari. We found that
initially the patients were very concerned about their own lives but
instinctively they protect their pregnancy by shielding the abdomen with
their hands (53%). The stressful state temporarily affects the fetal
movement’s perception. Nine patients graded their state as being concerned
to extremely concerned in a scale of 1 to 5.
In conclusion, pregnant women are concerned about their own lives as well
as
about their fetus. A Reduction in the perception of fetal movements with a
recovery after several hours is common. The psychological effects of a
life
threatening disaster on pregnant women should be further investigated by
large studies.
Introduction
An earthquake may be a significant threat to life causing casualties
and
loss of property. On August 17, 1999 at 03:04 am, an earthquake of 7.4
Richter scale struck the Marmara region, one of the most
populated
areas of Turkey. The estimated number of casualties was 50,000, of them
20,000 fatalities and another 20,000 people missing.
Pregnancy is the time in our life representing more than any other period
the continuation of life and expectations for a brighter future. Any
threat
to the well being of the Individual, loss of life in the family or
significant property damage may affect the physical and emotional well
being.
The purpose of this manuscript is to look at few aspects of pregnant
women’s
behavior and emotions during and after the earthquake.
Methods
The earthquake significantly damaged the infrastructure of the cities
including that of the health system. Many local medical personnel and
facilities were either hurt, killed, or destroyed, respectively, which
also
made the remaining medical facilities ineffective.
The Israeli defense forces (IDF) have sent a field hospital to the
affected
area in order to assist and substitute for some of the hospital facilities
and services that were significantly damaged in the earthquake. The IDF
field hospital started to function from day 4 to day 14 after the
earthquake
in the city Adapazari - the second most severely damaged city in Turkey.
One of the departments of the field hospital was Obstetrics and
Gynecology.
The services offered by the department were mostly routine primary and
secondary care including operating facilities, which have not been
functioning in the local medical facilities in the first week after the
earthquake. 123 patients were treated at the obstetrics and gynecology
department during the 10 days hat the hospital functioned.
A sample of 15 pregnant patients was selected to fill a questionnaire. An
English Turkish translator assisted an obstetrician to obtain the
responses.
Most patients that were requested to fill in the questionnaire complied.
Questionnaire form
Results
The earthquake occurred at 03:04 AM and all patients were inside
buildings,
11 were at home three stayed at relative's house and one was admitted to a
hospital at the time of the earthquake. All 15 patients were accompanied
by
family members during the occasion. 13 were with their husbands, five had
other children with them to rescue and six were staying with other
relatives
as well. 14 patients were at sleep and one was awake during quake. The
patients were asked what was the first action they did while the
earthquake
took place. Six patients fled immediately. Five screamed without taking an
immediate response until the quake was over. Three patients started
praying
and a few were hugged by their husbands. No patients looked for an
immediate
shielding for themselves like finding shelter under the beds. 8 out of the
15 (53%) patient shielded their abdomen during the earthquake in order to
reduce chances of trauma to the fetus. The most common method was by
covering the abdomen by hands while other were hugged by husband while
creating a barrier between the falling objects on or near them.
The patients were asked what was the first thing that crossed their
mind
during the earthquake. Most patients thought about the threat to their own
lives. Only one thought first on their children or husband. Two of the
fifteen pregnant women were injured during the earthquake. The injuries
were
mild.
Seven patients (46%) felt a reduction in fetal movements after the
earthquake. The movements were regained the sense fetal movements within a
couple of hours of the earthquake and all fetuses were evaluated
sonographically and score 8 of 8 on the revised manning biophysical score
(1).
At the time of the medical encounter, prior to the ultrasound
examination
was performed 8 of 15 patients scaled their level of concern for the fetal
well being as concerned to extremely concerned. The rest of the patients
were mildly or not concerned. The patient’s self-grading of anxiety was
tested again after the ultrasound test. The women observed the screen
during
the test. The examiner pointed out the fetal heart beat as well as the
fetal
movements. Six patients said that they feel calmer after the test and only
one said she is still extremely anxious. The average anxiety score after
the
test was 1.75 compared with 2.9 before the ultrasound test in a scale of 1
to 5 where 1 is calm and 5 is extremely anxious.
Discussion
A natural disaster has been defined as a disruption of human ecology
that
exceeds the capacity of the individual or community to function normally.
The event is usually very dramatic and in the case of an earthquake is
sudden, short and terrifying. Fear and anxiety are natural responses to
situation in which casualties are claimed and thousands literally lost all
their belongings.
Pregnancy is a special situation in human being `s life and it
represents
the continuation of the individual’s life as well as the next generation
to
come. Pregnancy can be a stressful situation especially when the family
confronts matters of survival, hunger and loss of shelter as well as the
pregnancy itself.
Lately there have been several studies suggesting correlation between
mass
casualties and adverse reproductive outcomes like, stillbirths, serious
developmental disabilities such as cerebral palsy and mental retardation ,
infertility early pregnancy loss (2,3).
On the 2nd of March 1985, 8-9 Richter scale earthquake and a series of
aftershocks took place in Santiago, Chile. The characteristics of over
22,000 births registered in three public hospitals in the same year were
reviewed. A significant increase in the rate of facial clefts was found.
2.01 per 1000 births in contrast to 1.6 per 1000 births in previous years.
The increase was greater in those born in September: 3.8 per 1000 births.
This increase in clefting could be related to the effects of stress
in
mothers induced by the earthquake. The authors have applied and to test
this
hypothesis 13.5-day-old embryos from two inbred mouse strains, A/Sn and
C57BL/10, were subjected to a similar stress using a vibrator cage to
imitate the main shock and the first five replicas of the earthquake. The
same intensity and duration of shock as in the original earthquake were
applied. The results were 19.8% cleft palates in stressed A/Sn mice and no
clefting in C57BL/10. These findings in mice support the stress hypothesis
for the increase in cleft palate observed in humans. The increase in
reabsorbed embryos in both strains also suggests an effect on stress. The
long-term effects of the earthquake on reproductive outcome in the Turkish
population should be examined in future studies.
Nevertheless, the affect of anxiety on pregnancy outcome is
controversial.
Other studies found little association between psychological scores and
physiological stress hormone concentrations. These studies could not
demonstrate a correlation between stress and adverse pregnancy outcome
(4).
A reduction in the average anxiety grading of 2.9 to 1.75 after the
ultrasound examination warrants the use of this tool for both diagnostic
test as well as for patients reassurance.
The limitations of our study are major. The sample size is small
there in no
control group of non-pregnant women or stress levels of pregnant women not
exposed to a natural disaster. The interviews were prepared and performed
by
physicians not trained specifically as behavioral sciences.
On the contrary, this survey is to the best of our knowledge the first to
describe the emotional process pregnant woman go through during and after
the disaster with respect to their own well-being and that of their
pregnancies. The survey showed that initially the patients are very
concerned about their own lives but instinctively they protect their
pregnancy by shielding the abdomen with their hands (53%).
The stressful state temporarily affects the fetal movement’s perception.
It
is not clear whether there is a true temporary reduction whether there is
only reduction of women’s perception. Studies in sheep correlated
increased
catecholamines to increased fetal movements (5). Nine patients graded
their
state as being concerned to extremely concerned in a scale of 1 to 5.
After
the sonographic test ten of the fifteen patients (75%) said that they
would
define their current emotional status as calm up to anxious. Three
patients
felt extremely concerned even after the test. Sonography has been shown to
be a technology that may reassure expecting mothers on one hand while
alarming others depending on the clinical setup. Based on our limited data
on mother’s concerns about their pregnancies, it seems that sonographic
testing of the pregnancies, showing the mothers the screen including fetal
heart beats and fetal movements has a reassuring role as well as a
diagnostic test for better care of pregnant women during mass casualties.
In conclusion, This small survey draws some light at what pregnant
women
feel and do during and several days after an earthquake. Concerns
regarding
their own life followed by worries about the fetal well being are immense.
Reduction in the perception of fetal movements with a recovery after
several
hours is common. Ultrasound demonstration of fetal biophysical score to
both
the health providers as well to the worried mothers is an important tool
for
reassurance.
Acknowledgment
This article is devoted to the 15 new lives that were given birth in
the IDF
field hospital in Adapazari. We wish to express our gratitude to the 102
members of the IDF field hospital and the Turkish volunteers that assisted
us day and night in the care of the people in Adapazari. Specifically in
this survey helped Ms Basak Duru which assisted in the communication
between
our patients and us.
References
1) Manning FA, Platt LD, Sipus L, Antepartum fetal evaluation: The
development of fetal biophysical profile score.Am J Obstet Gynecol 1980;
136:787.
2) Cordero JF, The epidemiology of disasters and adverse reproductive
outcomes: lessons learned. Environ Health Perspect, 1993; 101: 131-6.
3) Montenegro MA, Palomino H, Palomino HM. The influence of
earthquake-induced stress on human facial clefting and its simulation in mice.
Arch
Oral Biol 1995; 40: 33-7.
4) Milad MP, Klock SC, Moses S, Chatterton R. Stress and anxiety do
not
result in pregnancy wastage. Hum Reprod 1998 ; 13: 2296-300.
5) Boddy K, Dawes GS, Robinson JS:A 24 –hour rhythm in the fetus:
Foetal and
neonatal physiology. Proceedings of Sir Joseph Barecroft Centenary
Symposium. Cambridge, July 25, 1972, London, Cambridge University Press,
1973.
Competing interests: ____________________________________________________________