The Awareness and Knowledge of Normal and Abnormal Signs and Symptoms of Pregnancy Among Women of Childbearing Age in Saudi Arabia

Background: Pregnancy is a natural physiological process that leads to the outstanding outcome of giving birth. It involves normal and abnormal signs and symptoms that women need to be aware of during this period. Objectives: This study aims to assess the awareness and knowledge about normal and abnormal signs and symptoms of pregnancy among women of childbearing age in Saudi Arabia. Methods: This is an online questionnaire-based cross-sectional study done in 2023 among women in Saudi Arabia, aged 18 to 45. The estimated sample size was 385 after applying inclusion and exclusion criteria. However, 981 responses were collected and included. Results: A total of 981 participants were included in our study. The study findings noted that the majority of women demonstrated a good level of knowledge about the normal signs and symptoms of pregnancy. About 82% of the women reported that they knew mood swings were normal symptoms during pregnancy, 80.1% were aware of nausea, 75.9% knew about fatigue, and 68.9% knew about fainting or dizziness. The findings noted that less than half of the participants were fully aware of the abnormal obstetric signs. For the abnormal signs and symptoms during the first trimester, only 45.2% were fully aware of the symptoms. In the second trimester, 39.0% were fully aware of the symptoms. Only 30.5% of the participants were fully aware of the abnormal signs and symptoms in the third trimester. The study established a statistically significant relationship between age and knowledge of abnormal symptoms during the first, second, and third trimesters (P=0.027, 0.041, and 0.006) (r=0.139, 0.105, and 0.146). Furthermore, a statistically significant relationship was found between the level of education of the participants and the level of awareness of abnormal symptoms during the first trimester (P=0.043). However, there was no significant relationship between education level and the level of knowledge regarding abnormal symptoms during the second and third trimesters (r=0.22, 0.061, P=0.578, 0.603). Conclusion: The study found that the majority of women had a good level of awareness and knowledge about normal signs and symptoms of pregnancy, while less than half of the women were fully aware of the abnormal signs and symptoms at different stages of pregnancy. The older respondents and people with higher levels of education demonstrated more knowledge. The two variables, age and education level, had a statistically significant relationship with knowledge of abnormal signs and symptoms of pregnancy with education level being only significant during the first trimester period. Our study concluded that women had different symptoms during pregnancy, both normal and abnormal. Their knowledge about these signs and symptoms was considerably moderate, but further awareness about the normality of these signs is needed. The study recommends more research to measure women's awareness about normal and abnormal symptoms of pregnancy, and more awareness programs should be carried out in the region as a way of enhancing a better understanding of normal and abnormal pregnancy symptoms. This will go a long way in helping women through their pregnancy and make them more comfortable.


Introduction
Every woman has a different experience during pregnancy with wide variation in signs, symptoms, and physiological changes [1].Significant physical and psychological changes occur throughout pregnancy.These changes influence the quality of life of pregnant women and have an impact on the health of both the mother and her child [2].Theoretically, women can conceive from the time they have their monthly cycles, known as menarche, during adolescence until they reach menopause, which is the end of the monthly cycle.This time frame is known as the "childbearing age," with menarche as the start and menopause as the end.
The average woman's reproductive years last from 12 to 51 years [3].Hormonal, physical, and psychological changes during pregnancy contribute to the variation in the signs and symptoms among women.Early warning signs include fatigue, tender breasts, nausea with or without vomiting, increased urination, and changes in bowel habits like constipation, abdominal bloating, and light spotting.Cramping may also occur.The earliest and most reliable sign is a missed period [4].When it comes to the gestational period, a singleton pregnancy typically lasts 40 weeks (280 days) from the first day of the last period to the scheduled delivery date.Previously, "term" was referred to the timeframe that started three weeks before the planned delivery date and ended two weeks later.This was with the goal of consistent and positive newborn outcomes from deliveries over this time period [5].The high level of knowledge about the signs and symptoms of pregnancy has a notable effect on increasing women's interest in their health during the prenatal period and increasing their commitment to attending prenatal clinics.About 85% of women who are pregnant have consideration about pregnancy-related symptoms during the preventive health checks performed by their GP or midwife [6].Health records promote a biomedical focus on serious health issues, while symptoms, such as nausea, are given less attention as they may be present in otherwise normal pregnancies.Pregnancy-related physical symptoms are common throughout the first trimester [7].Nausea is reported by approximately 80% of women, while vomiting affects 35-40% throughout the first trimester [8,9].Frequencies in the order of 25-50% have also been described for symptoms such as vulvar itching, vaginal bleeding, and pelvic cavity pain [10].Pelvic girdle pain and low back pain symptoms (or, in some studies, a combination of these two referred to as "lumbopelvic pain") are often reported for all three trimesters, with a prevalence of 20-65% [11].It's important to note that some symptoms might indicate a pathological pregnancy, but most are physiological changes that normally occur as a result of pregnancy [12].As the harm of these symptoms is not well understood, physicians may be ignorant of the concerns of their pregnant patients.It has only been studied in a few studies how women feel about their pregnancyrelated physical symptoms [13,14].It has been reported that various depression and anxiety measuring instruments, such as the Cambridge Concern Scale, have been used to assess maternal stress or worries during pregnancy, but these measures are global in nature and do not address the impact of specific symptoms [15].This study aims to assess knowledge about normal and abnormal signs and symptoms of pregnancy among women of childbearing age in Saudi Arabia.

Materials And Methods
This is a cross-sectional study that was conducted in Saudi Arabia in 2023.The online questionnaires were distributed via social media including Twitter, WhatsApp, and Telegram to collect data.The target population was women between the ages of 18 and 45 in all regions of Saudi Arabia.The inclusion criteria were women aged between 18 and 45 who have at one point in time been pregnant, in Saudi Arabia, Arabic speakers, and residents of Saudi Arabia.The exclusion criteria were the minors (less than 18 years) who had never been pregnant and those who declined to participate in the study.The sample size was calculated based on an infinite population and estimated as 50%.Using a 95% confidence interval and a 5% margin of error, the calculated sample size was 385.The sample size was calculated using a Raosoft calculator (Raosoft, Inc., Seattle, WA 98115, United States).However, the study involved 981 participants who completed the online questionnaires.
The questionnaire comprised of sociodemographic and obstetrical characteristics of participants.

Results
A total of 981 participants were able to complete the online questionnaires.Most of them were within the age group of 36-45 years (35.8%).A large percentage of participants (88.3%) were Saudi nationals; more than two-thirds of the participants were married at the time of the study (69.4%), and 71.1% had a bachelor's degree.Regarding employment status, 43.6% were unemployed/housewives and 31.8% were employed.Their economic status was as follows: <5000 SR (65.9%), 5000-10000 (19.6%), and 10000-15000 (15.9%).About 10.6% of the participants were smokers (Table 1).

TABLE 1: Demographic characteristics of the study participants (n=981)
In terms of clinical characteristics of the participants, 79.9% reported that they didn`t have chronic diseases, 31.8% were O+ blood grouping, and 28.5% were A+.About the number of their children, 42.7% of the participants reported that they had one to three children, 33.3% had none, and 22% had four to six children.About 27.7% were pregnant two to three times, and 21.3% were pregnant four to five times.Regarding abortion history, 73.2% never had it, and 22.9% had it less than three times.About 88% of them were not pregnant at the time of the study, 49.7% knew they were pregnant by using a home pregnancy test, and 24.9% had never been pregnant.About 60.8% of the respondents used a folic acid supplement, and 32.6% didn`t (Table 2).Regarding the knowledge of normal pregnancy symptoms, 82% of the participants reported that they knew that mood swings were a normal symptom during pregnancy, 80.1% were aware of nausea, 75.9% knew about fatigue, 68.9% fainting or dizziness, 67.4% and 67.1% knew of heartburn and vomiting, respectively, and 65.9% knew cravings or an extreme aversion to eating and vaginal discharge with no itching.Only 25.9% of the respondents were aware that those symptoms still persist (Table 3).

TABLE 3: Knowledge of normal pregnancy symptoms
Considering the awareness of abnormal signs and symptoms occurring during different stages of pregnancy including the first, second, and third trimesters, persistent mood swings were the most known abnormal symptoms (82%), followed by persistent nausea (80.1%) and severe fatigue (75.9%).During the first trimester of pregnancy, persistent mood swings and persistent nausea were the most known abnormal symptoms.During the second trimester, back pain (65.5%) was the top-mentioned symptom followed by stretch marks in the skin (59.8%) and then headache (48.9%).During the third trimester, frequent urination (65.4%) was the most known symptom followed by difficulty sleeping (57.2%) and lower limb edema (49%) (Table 4).

TABLE 4: Proportion of women who reported knowledge of abnormal symptoms in the first, second, and third trimesters
Considering the awareness of obstetric and abnormal signs and symptoms, less than half of the participants were fully aware of the abnormal obstetric signs.For the abnormal signs and symptoms during the first trimester, only 45.2% were fully aware of the symptoms.In the second trimester, 39.0% were fully aware of the symptoms.Only 30.5% of the participants were fully aware of the abnormal signs and symptoms in the third trimester (Table 5).

TABLE 5: Knowledge of obstetric and abnormal signs and symptoms
In the assessment of factors associated with increased awareness levels during the three stages of pregnancy, certain factors were found to be related to the level of awareness.A significant positive correlation exists between age and knowledge of abnormal symptoms during the first, second, and third trimesters (P=0.027,0.041, and 0.006) (r=0.139,0.105, and 0.146), indicating that older females have a better level of knowledge compared to younger participants.Furthermore, a significant positive correlation was found between the level of education of the participants (P=0.043);however, the education level is only significant in the awareness of abnormal symptoms during the first trimester, but no significant association was found between education level and the level of knowledge regarding abnormal symptoms during the second and third trimesters (r=0.22,0.061, P=0.578, 0.603).Nationality was not associated with any of the knowledge categories (P=0.064,0.691, 0.205).Additionally, marital status, employment status, economic status, and smoking status were also not associated with any of the knowledge categories as indicated by (P=0.079,0.802, 0.411), (P=0.063,0.690, 0.341), (P=0.134,0.397, 0.512), and P=0.105, 0.598, 0.319), respectively.Additionally, marital status, economic status, and smoking status were not associated with any of the knowledge categories (Table 6).

Discussion
It is a fact that women's bodies go through some changes during pregnancy, and these changes are usually normal but sometimes can be uncomfortable.Abnormal signs and symptoms may end with serious complications women could spare like morning sickness that may lead to hyperemesis gravidarum and make women uncomfortable and scared; therefore, good awareness is essential to guide women through this period safely.This study's main objective was to assess the level of awareness and knowledge about normal and abnormal signs and symptoms of pregnancy among women of childbearing age in Saudi Arabia.The study findings noted that the majority of women demonstrated a good level of knowledge about the normal signs and symptoms of pregnancy.The vast majority, 82% of the participants, reported that they knew mood swings were normal symptoms during pregnancy, 80.1% were aware of nausea, 75.9% knew about fatigue, 68.9% knew about fainting or dizziness, 67.4% and 67.1% knew of heartburn and vomiting, respectively, and 65.9% knew cravings or an extreme aversion to eating and vaginal discharge with no itching.This finding is similar to the results of a study conducted by Amasha in Jordan which found that more than half of the sampled women were aware that fainting/dizziness, nausea, abdominal cramps, fatigue, and mood swings were normal symptoms of pregnancy [16].The findings are also in agreement with a study conducted by Emelianova et al. on 193 pregnant women in Canada which found that 67.4% of the women experienced nausea and vomiting [17].A similar study by Quaresma et al. conducted in Portugal on 49 pregnant women reported that 71.4% and 91.7% of the women were aware that back pain at 12 weeks and 37 weeks were symptoms of pregnancy [18].The findings established that persistent mood swings and persistent nausea were the most recognized abnormal symptoms during the first trimester, with back pain, stretch marks, and headache being the most known symptoms during the second trimester, while frequent urination and lower limb edema being the most known abnormal symptoms during the third trimester.These findings are consistent with the findings of the study conducted by Okour et al. among women in Jordan which found that the majority of the women recognized severe headache, back pain, and swelling of the lower limb as the symptoms of abnormal pregnancy [19].
On the other hand, considering the awareness of obstetric and abnormal signs and symptoms, less than half of the participants were fully aware of the abnormal obstetric signs.For the abnormal signs and symptoms during the first trimester, only 45.2% were fully aware of the symptoms.In the second trimester, 39.0% were fully aware of the symptoms.Only 30.5% of the participants were fully aware of the abnormal signs and symptoms in the third trimester.The reported finding is higher than the reported finding by Abu-Shaheen et al., in which it was reported that only 13.5% of the women were knowledgeable about the three complications during pregnancy followed by 3.4% who were able to identify three complications during labor and the postpartum period [20].The findings might indicate inadequate education by the healthcare providers during the antenatal visits and other education programs.Therefore, teaching and emphasizing the abnormal signs and symptoms should be included in the health education program during the antenatal period.It is imperative to note that knowing abnormal signs and symptoms would not necessarily ensure that pregnant women could recognize the severity of the problem.Healthcare personnel should also inform all pregnant women to be aware of the abnormal signs as well as go to the hospital as soon as such abnormal symptoms occur.
The study established a statistically significant relationship between age and knowledge of abnormal symptoms during the first, second, and third trimesters (P=0.027,0.041, and 0.006) (r=0.139,0.105, and 0.146) indicating that older females have a better level of knowledge compared to younger participants.Furthermore, a statistically significant relationship was found between the level of education of the participants and the level of awareness of abnormal symptoms during the first trimester (P=0.043).However, there was no significant relationship that was found between education level and the level of knowledge regarding abnormal symptoms during the second and third trimesters (r=0.22,0.061, P=0.578, 0.603).The study findings suggest that age and level of education were significantly associated with the level of knowledge of abnormal signs and symptoms at different stages of pregnancy.In regards to age, females above 26 years of age had better awareness of abnormal signs and symptoms than the younger age.This finding is consistent with Chortatos et al. in which it was reported that females older than 25 years had better awareness of obstetric abnormalities and complications during pregnancy [21].Considering the education level, 95.2% of the participants had attained secondary education and above; hence, they had a good understanding and knowledge of normal and abnormal signs and symptoms of pregnancy.This was shown to be positively correlated with the level of awareness of abnormal symptoms during the first trimester.

Limitations
The main limitation of this study is that data were collected via a self-reported survey through online networks which may be influenced by reporting bias.

Recommendations
We recommend that more research should be conducted to measure women's awareness about the normal and abnormal symptoms of pregnancy, and more awareness programs should be carried out in the region as a way of enhancing a better understanding of normal and abnormal pregnancy symptoms in order to aid them through their pregnancy and make them more comfortable.

Conclusions
The findings in this study indicated that the majority of the women had a good level of awareness of normal signs and symptoms of pregnancy, while less than half of the women were fully aware of the abnormal signs and symptoms at different stages of pregnancy.The older respondents and people with higher levels of education demonstrated more knowledge.The two variables, age and education level, had a statistically significant relationship with the knowledge of abnormal signs and symptoms of pregnancy with education level being only significant during the first trimester period.Based on the findings of this study, women experienced different signs and symptoms during pregnancy, and many of them are clear and others are unclear.A high knowledge of the signs and symptoms of pregnancy is crucial to women of reproductive age to aid them through pregnancy and make them comfortable.

Appendices
aware p-value Not aware Fully aware p-value Not aware Fully aware p-value Age (in years)

Knowledge of abnormal symptoms in the first trimester Yes No
Knowledge of abnormal symptoms in the second trimesterYes No 2023 Alharbi et al.Cureus 15(8): e44470.DOI 10.7759/cureus.444705 of 14

TABLE 6 : Factors associated with increased awareness level about abnormal symptoms during the first, second, and third trimesters
*Significant when the p-value is lower than 0.05