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Validation of the intolerance of uncertainty scale-12 in a sample of pregnant people

BMC Pregnancy and Childbirth volume 25, Article number: 363 (2025) Cite this article

Abstract

Background

Intolerance of uncertainty (IU) has been proposed as a transdiagnostic mechanism driving anxiety, depression, and eating disorder symptoms. Pregnancy is a time of significant uncertainty, yet few studies have examined the measurement of IU and its impacts on pregnant people. The current study aimed to examine the psychometric performance of two versions of the Intolerance of Uncertainty Scale (IUS-27 and IUS-12) and their associations with psychopathologies common in pregnancy.

Methods

This study is a secondary analysis of participants (n = 254) recruited for a larger study of a single-session intervention targeting disordered eating in pregnancy. We examined fit of participant baseline data with IUS-27 and IUS-12 factor structures using confirmatory factor analyses. We also assessed associations between IU and emotion dysregulation and depression and eating disorder symptoms, controlling for age, parity, and perceived social status.

Results

The IUS-12 provided superior fit to the data (CFI = 0.95; TLI = 0.93; RMSEA = 0.09) compared to the IUS-27. The IUS-12 was significantly (all p < 0.05) correlated with measures of emotion dysregulation (r = 0.67), depression (r = 0.58), and eating disorders (r = 0.37). Inhibitory IU rather than prospective IU was generally significantly associated with greater psychopathology (ß range = 0.46 – 3.51, p’s < 0.01).

Conclusions

Results from this study provide initial support for the IUS-12 as a valid measure of IU in pregnant people and suggest that IU is strongly associated with measures of depression, emotion dysregulation, and eating disorder behaviors in this population. Severe psychological distress in pregnancy has been linked to complications in gestation and delivery and overall poor birth outcomes. Clinicians and doctors should consider using the IUS-12 as a general measure of psychological distress among pregnant patients.

Trial registration

The trial from which these data were drawn is registered at clinicaltrials.gov, NCT06129461 (registered on November 10, 2023).

Peer Review reports

Background

Pregnancy is typically a time characterized by both excitement and uncertainty [45]. Each pregnancy involves changing internal and physical states as well as concurrent worries about fetal viability and maternal health. In pregnant populations, greater uncertainty has been associated with less social support and poorer psychological well-being [12, 29]. Prolonged stress, in turn, is associated with increased risk of adverse outcomes during pregnancy, delivery, and the postpartum period [67]. Given our understanding of the potential significant impacts of uncertainty on the experience of pregnancy and mental health outcomes it is important to determine appropriate measurement of this construct in pregnant individuals.

Intolerance of uncertainty (IU) is a dimensional trait defined as an intolerance of ambiguity and/or uncertainty across different domains [10]. People with high levels of IU tend to report uncertainty as threatening, distressing, and unacceptable accompanied by heightened physiological arousal and stronger negative affective states [20, 53, 53, 54, 54]. This intolerance can lead to significant adverse psychological and behavioral outcomes. Research to date has demonstrated a significant association between IU and excessive worry [6], maladaptive emotion regulation [61], anxiety disorders [27, 40], and eating disorders [8] in non-pregnant samples. IU has been additionally linked to depression [6, 27], this association is typically similar to effect estimates of IU on anxiety disorders [49]. Based on these findings, IU has been proposed as a transdiagnostic mechanism that could potentially be targeted to relieve a variety of psychological symptoms [6, 49]. Interventions targeting IU have demonstrated effectiveness in reducing anxiety [23, 35].

Pregnancy is a high-risk period for the development and exacerbation of diverse psychopathologies. Perinatal anxiety and depression are two well-studied complications during pregnancy as they both significantly predict birth complications and post-partum anxiety and depression [22, 37]. Though these psychiatric disorders and symptoms occur frequently in pregnant people, oftentimes they go undetected [30]. Additionally, women with a history of or an active eating disorder are more likely to experience cognitive symptoms of an eating disorder and exhibit eating disorder behaviors throughout pregnancy [51]. Early detection and treatment are essential to mitigating risk and suffering in both parents and children.

Among pregnant people, higher IU is associated with lower levels of psychological well-being regardless of objective risk of negative outcomes or complications during pregnancy [14], though those with higher risk pregnancies tend to have qualitatively higher levels of IU compared to those with low risk pregnancies [12]. Most pregnant people experience some level of fear around the birthing experience regardless of parity status. More severe fear of childbirth was associated with higher levels of IU [25, 33]. These preliminary findings suggest that understanding measurement accuracy and exogenous factors that impact IU is important to the detection, prevention, and treatment of psychological disorders in the perinatal period.

Currently, the Intolerance of Uncertainty Scale-27 (IUS-27; [9]) and the Intolerance of Uncertainty Scale-12 [63] are the most used self-report measures of IU. The IUS-27 has been demonstrated to be a valid and reliable measure of IU among clinical [46, 50] and community samples [5]. One study to date has explored the predictive validity of the IUS-27 in pregnant people and found that this measure is a useful metric for screening and detecting perinatal anxiety disorders [26]. However, since IU is demonstrated to be a transdiagnostic mechanism [6], examination of IU and its relation to symptoms of other psychiatric disorders in pregnancy is warranted. Furthermore, the validity of measures of IU has not been examined among pregnant populations.

This study sought to examine the psychometric properties of both the IUS-27 and IUS-12 in a sample of pregnant people using a series of confirmatory factor analyses (CFA) to determine the most appropriate measure of IU during pregnancy. This study further examined the relationship of IU as a transdiagnostic risk and maintaining factor for emotion dysregulation, depression, and eating disorder symptoms. We planned to use the measure with the best fit indices (IUS-27 vs. IUS-12) to explore the measurement’s associations with measures of emotion dysregulation, depression, and eating disorder symptoms. We predicted that the best fit measure of IU will be more strongly associated with measures of emotion dysregulation and eating disorders, and less strongly associated with a measure of depression.

Research on the impact of exogenous factors on the measurement of IU in pregnant populations remains limited, highlighting the need to explore how these factors influence self-report measures. Certain social factors have been found to exacerbate anxiety, depression, and eating disorder symptoms. Those with a higher perceived social status tend to report overall better physical health, particularly in the United States [19]. Additionally, parity and age have been preliminarily associated with emotional disorders among pregnant populations such that multipara parents typically report higher levels of both anxiety and depression during pregnancy [21]. In addition, age has been demonstrated to have an inverse relationship with symptoms of anxiety [4], while symptoms of depression appear to either follow a U-shaped pattern with lowest levels in middle age [2, 65] or linearly increase across time [64]. Based on these findings, our exploratory hypothesis was that age, parity, and perceived social status will significantly contribute to the variance in scores on the best fitting IU measure.

Methods

Participants

Data for this study came from 269 pregnant people enrolled in a larger study examining the impact of a single session acceptance and commitment therapy intervention on eating disorder symptoms among pregnant people [38]. Participants were recruited via the Prolific platform [56] and provided a waiver of consent prior to completing a battery of self-report online questionnaires. Inclusion criteria for this study required participants to be 18 years or older, reside within the United States, read and write fluently in English, and currently pregnant. Participants (n = 15) were excluded from the study if they reported a due date that was more than 30 days from a probable due date calculated by the researcher from participants’ responses to the number of weeks pregnant at the time of survey completion. This resulted in a total of 254 participants included in the analyses reported here.

The Institutional Review Board at the University at Albany, State University of New York approved this study protocol. Participants received monetary compensation for their participation and, as part of the larger study, a subset of participants were provided with a free single session intervention aimed at reducing the adverse impact of food cravings on eating behaviors [38]. All data in this study were collected at baseline prior to the administration of any intervention. Participant demographics are presented in Table 1. Time to complete the survey (M = 28.67 min, SD = 47.36 min) was examined as a check for data quality, no participants were excluded based on their time to complete the survey.

Table 1 Participant demographics
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The larger study from which the data for this study was collected is registered on clinicaltrials.gov (NCT06129461).

Measures

Participants completed a brief demographic survey prior to responding to a battery of self-report questionnaires. Participants were asked their current age, race and ethnicity, and employment. In addition, participants were asked to provide information relevant to their pregnancy, including weeks gestation at the time of survey completion, expected due date, and parity, before completing the following measures:

Intolerance of Uncertainty Scale (IUS-27; [9]): The IUS-27 is a 27-item self-report measure of various cognitive and behavioral aspects of intolerance of uncertainty. Participants rate each item on a five-point Likert scale (1 = Not at all characteristic of me; 5 = Entirely characteristic of me) with higher scores indicating a greater intolerance of uncertainty. Items are added to create a total score (range: 27 – 135) and two subscales ("Uncertainty has negative behavioral and self-referent implications” and “Uncertainty is unfair and spoils everything"; [63]).

Intolerance of Uncertainty Scale-12 (IUS-12; Carleton et al.): The IUS-12 is a short form self-report measure of IU derived from the IUS-27. Items are summed to create a total score and two subscales (“Prospective IU” and “Inhibitory IU”). The IUS-12 has been validated among community [13] and clinical populations [50]. There has been debate over which form of the IUS to use, though preliminary evidence suggests that the IUS-12 is a more accurate measurement of IU and is gender invariant [57]. No studies to date have examined the psychometric properties of the IUS-12 nor the IUS-27 in pregnant people.

Difficulties in Emotion Regulation Scale (DERS-36; [31]): The DERS-36 is a 36-item self-report measure of multiple aspects of emotion regulation including emotional awareness, activation, and acceptance. Participants rate each item on a five-point Likert scale (1 = Almost Never; 5 = Almost Always). The DERS-36 has six subscales, but the current study examined the total score exclusively which is the sum of all items (Cronbach’s α = 0.96). Total scores on the DERS-36 range from 36 – 180, and among community samples scores of 75.26 are considered normal and scores 116.13 and above indicate severe emotion dysregulation [11]. The DERS-36 was included here based on prior work suggesting that greater difficulties in emotion regulation are indicative of elevated levels of depression [42], anxiety [15], and eating disorders [47].

Edinburgh Postnatal Depression Scale (EPDS; [17]): The EPDS is a 10-item self-report measure of depressive symptoms during the perinatal period. Items are rated on a four-point Likert scale and summed to create a total score (range: 0–30; baseline Cronbach’s α = 0.90). A total score of 12/13 or higher is used as a cutoff for a high likelihood of a depressive disorder and 9/10 as “possible depression” [17]. The EPDS has been widely validated as a screening measure for depression among pregnant people though it is best used as a rule-out for depression rather as a rule in [28]. The measure was included here to try and replicate documented links between IU and depressive symptoms in non-pregnant populations.

Prenatal Eating Behaviors Screening Tool (PEBS; [16]): The PEBS is a 12-item self-report measure of eating attitudes and behaviors specifically during pregnancy and suitable for screening pregnant people for eating disorders across all trimesters. Participants rate each item on a five-point Likert scale and a total score is derived from adding all items together. A total score of 39 or higher is indicative of an eating disorder [16]. The PEBS was administered to examine hypothesized links between IU and disordered eating behaviors in pregnancy. Baseline Cronbach’s α was 0.88 for this study.

Perceived Social Status Scale (PSS; [3]): The perceived social status scale is a measure of subjective social status and has been demonstrated to significantly correlate with psychological and physical well-being [62]. Participants are asked to consider their position in society including education, salary, and living situation and then place themselves on a rung of an imagined ladder. The ladder has six rungs, with the sixth and highest rung representing people who are most well-off and the first and lowest rung representing people who are worst-off.

Statistical analyses

All statistical analyses were conducted in RStudio v. 4.3 [60]. Responses to all psychological measures that were above or below the 95th and 5th percentiles, respectively, were winsorized and included in analyses. We assessed fit of the data with the established IUS-27 and IUS-12 factor structures in confirmatory factor analysis (CFA) using the “lavaan” package [59] and specifying an oblique rotation following what was done by Sexton and Dugas [63] and Carleton et al. [13]. We examined the comparative fit indices (CFI), Tucker-Lewis Index (TLI), and root mean square error of approximation (RMSEA) for model fit using recommended coefficients [39].

The IUS has a robust theoretical foundation with a well-defined factor structure that has been replicated in diverse populations. We conducted CFA, rather than exploratory factor analyses, because our main aim was to test whether these established structures hold in a novel population of pregnant individuals, rather than exploring potential new factor structures. This approach is comparable to that taken in similar prior studies [36, 44, 68]. This study is a secondary analysis of an existing data set; as such, there was no a priori power analysis. Of note, our sample size exceeded the common recommendation of a minimum 4:1 ration of respondents to variables to ensure stability of a factor solution [48], and approximates the more conservative guidance to include at least 10 respondents per parameter [43].

Regression analyses using the “lavaan” package [59] were used to examine the relationships between the best fitting measure of IU and relevant and related measures of depression and eating disorder symptoms. Given that IU has been strongly implicated in emotion regulation processes, we examined the relationship between the IUS-12 and DERS-36 to determine convergent validity. Age, parity, and perceived social status were added to the models as covariates on theoretical grounds. For all regression analyses only participants with complete data were included (n = 224).

Results

Item means, standard deviations, and skewness are reported in Table 2 for all 27-items on the IUS. Higher scores on IUS-27 items are reflective of a higher intolerance of uncertainty. Average scores on the EPDS were above the threshold for possible depression (M = 9.76, SD = 5.90) and participants also endorsed elevated levels of difficulties in emotion regulation on the DERS-36 (M = 87.99, SD = 25.18). On measures of eating disorder symptoms and behaviors, participants reported a mean score on the PEBS of 20.15 (SD = 7.02), which is below the established cutoff of 39 for the possible presence of an eating disorder diagnosis.

Table 2 Means, standard deviations, and skewness for each item on the Intolerance of Uncertainty Scale-12
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Confirmatory factor analysis of the IUS-27

Item reliability measures for all 27-items indicated excellent internal reliability (Cronbach’s α = 0.97; omega = 0.97). Participants reported a mean total score of 73.78 (SD = 22.81). Participants on average reported similar mean scores on both IUS-27 subscales (“Uncertainty has negative behavioral and self-referent implications:” M = 37.14, SD = 13.58, Cronbach’s α = 0.95; “Uncertainty is unfair and spoils everything:” M = 36.76; SD = 11.35, Cronbach’s α = 0.94). The two-factor structure of the IUS-27 resulted in good fit to the data (CFI = 0.90; TLI = 0.89; RMSEA = 0.08). Path diagrams showing standardized path coefficients are represented in Fig. 1A.

Fig. 1
figure 1

Standardized fit coefficients for confirmatory factor analyses. Note. Figure A depicts confirmatory factor analyses for the Intolerance of Uncertainty Scale-27; “fac1” = “Uncertainty has negative behavioral and self-referent implications”; “fac2” = “Uncertainty is unfair and spoils everything”; IUS = Intolerance of Uncertainty Scale. Figure B depicts confirmatory factor analyses for the Intolerance of Uncertainty Scale-12; “fac1” = “Prospective Intolerance of Uncertainty”; “fac2” = “Inhibitory Intolerance of Uncertainty”

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Confirmatory factor analysis of the IUS-12

Participants in our sample reported a mean total score on the IUS-12 of 34.56 (SD = 10.30) and significantly higher scores on the Prospective IU scale (M = 22.19, SD = 6.56) than on Inhibitory IU (M = 12.43, SD = 5.01), t(500) = 18.7, p < 0.001. Internal reliability coefficients indicated that the IUS-12 had excellent internal reliability (Total score Cronbach’s α = 0.94; omega = 0.94; Prospective IU Cronbach’s α = 0.89; Inhibitory IU Cronbach’s α = 0.89). The IUS-12 had excellent fit to the data (CFI = 0.95; TLI = 0.93; RMSEA = 0.09) and standardized path coefficients are represented in Fig. 1B. Even though the data demonstrated acceptable fit with both the IUS-27 and IUS-12 factor structure, the short version of the scale performed relatively better as reflected in the fit statistics examined. We therefore chose to proceed with the IUS-12 for all subsequent analyses.

Validity and regression analyses

Parametric correlations were run between the IUS-12 total scores and total scores of the other self-report measures (Table 3). The IUS-12 total scores demonstrated convergent validity with the DERS-36 (r = 0.64) and EPDS (r = 0.58). The IUS-12 was significantly and moderately correlated with the PEBS (r = 0.35).

Table 3 Means, standard deviations, and correlations with confidence intervals
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Next, we used a stepwise analysis to assess the amount of variance for each outcome accounted for by IU. The first step of the model included demographic variables (i.e., age, parity, perceived social status), and the second step introduced scores for the two subscale of the IUS-12 (Table 4). Step two models accounted for more variance in outcome scores on the EPDS, DERS-36 and PEBS compared to step one (ΔR2 range = 0.16 – 0.41). When incorporating IUS-12 subscale scores, age, parity, and trimester did not significantly contribute to any models. The higher rungs on PSS scale (levels 3–6) significantly contributed to the step one model for the EPDS, but only rungs 4–5 were significant predictors in step two of lower levels of perinatal depression (ß’s = −3.26 and −4.48, respectfully),. The Inhibitory IU subscale (Factor 2) was the only subscale that was significantly predictive of total scores on the EPDS (ß = 0.62, p < 0.01), DERS-36 (ß = 3.51, p < 0.01) and PEBS (ß = 0.46, p < 0.01).

Table 4 Unadjusted multiple linear regression results including demographic variables and Intolerance of Uncertainty Scale-12 subscales as predictors
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Discussion

Given that pregnancy is a time characterized by significant uncertainty for most, the reliable measurement of IU across all trimesters is critical. The objective of this study was to determine the most appropriate measure of IU among pregnant people using a series of confirmatory factor analyses. Though both CFAs suggested adequate fit, overall, the IUS-12 provided the best fit to the data. Specifically, the Inhibitory IU subscale was the most significant contributor to the association with depressive symptoms, difficulties in emotion regulation and pathological eating behaviors.

IU has been described as a transdiagnostic trait that is associated with anxiety, depression, and eating disorders [49]. Pregnant people are susceptible to these psychological symptoms, but emphasis is typically placed on medical care of both the mother and baby at the expense of mental health. Psychological symptoms are still largely stigmatized and mostly conceptualized to be a post-partum issue [24, 55]. Early detection across diagnoses is essential to better treatment outcomes for most psychiatric disorders and to reduce suffering among patients [41].

The IUS-12 showed a notable correlation to measures of emotion regulation and perinatal depression and a smaller, moderate correlation with eating disorders (Table 3). Previous research has examined the IUS-27 as a screening tool for perinatal anxiety [26], but to date, this is the first study to validate the IUS-12 and consider it as a transdiagnostic measure of emotion dysregulation, depression, and eating disorder symptoms using factor analysis among pregnant people. The IUS-12 can be used as a valid measure to indicate general psychological distress during pregnancy.

Multiple linear regressions examining the IUS-12 as a predictor of each outcome indicated that IU accounted for a significant amount of the variance across measures and drove a large portion of variance in total scores on the DERS-36, consistent with previous literature [61]. The DERS-36 has been associated with various anxiety disorders [32], eating disorders [34], and obsessive compulsive disorder [32]. The characteristic of viewing uncertain events and situations as threatening and intolerable is associated with both higher levels of anxiety and emotion dysregulation, which makes sense when considering that obsessive and compulsive behaviors are thought to reduce anxiety and uncertainty [1, 66]. These findings also align with previous literature suggesting that IU contributes significantly to eating disorder symptoms [8] and extends these findings to suggest that IU plays a significant role in psychological distress during pregnancy.

When examining exogenous variables that may contribute to outcomes associated with general psychological distress, contrary to our hypotheses, parity and trimester were not associated with measures of eating disorder symptoms, emotional dysregulation, and depression. However middle and higher PSS was associated with lower depression scores above and beyond IU. These findings might suggest that prior experience and pregnancy status do not have much influence on reports of symptomology especially when accounting for IU. Studies examining parity and IU have identified various findings on the impact of parity on anxiety, worry, depression, and IU [7, 58].

Limitations and future directions

Our study was a secondary analysis relying on data from a larger study. Though our sample size was consistent with comparable validation studies of the IUS [9], and fit indices for both the IUS-27 and the IUS-12 were good, they likely would be more substantial with a larger sample size. As our sample was comprised of people interested in participating in an intervention study, it is likely that our sample had a higher incidence of psychiatric symptoms, which may explain a higher average depression score in our sample. Future research should seek to replicate findings in larger clinical and non-clinical samples. Furthermore, our study did not examine IU measurement in relation to other measures of transdiagnostic traits including trait anxiety. Our study was unable to determine the specificity of IU in this population, and a future study would benefit from this consideration [52]. Additionally, future studies should examine the transdiagnostic predictability of the IUS-12 for anxiety, depression, and eating disorders among pregnant people. This current study did not collect information on psychiatric diagnoses and this prevented us from examining predictive validity of the IUS-12 for these various disorders similar to the examination conducted by Furtado et al. [26] on sensitivity and screening for anxiety disorders.

Conclusion

The current study was the first to investigate the factor structure of the IUS-27 and the IUS-12 among pregnant people and its transdiagnostic properties. Results from this study indicate that the IUS-12 would sufficiently capture IU among pregnant people across trimester. Additionally, the short form of the IUS-12 is less of a burden to complete by patients and to score/interpret by clinicians. Higher scores on the IUS-12 were significantly associated with more severe reports for depression, emotional dysregulation, and eating disorder symptoms. This implies that the IUS-12 would likely assist clinicians in screening for general transdiagnostic psychological distress. Pregnancy is often a time when people have increased contact with medical professionals, which allows for more oversight and opportunities for administering life-saving interventions. Transdiagnostic measurements allow for less patient and clinician burden and may allow for early detection and intervention to take place mitigating risk to both parent and child.

Data availability

All data is available from the corresponding author upon reasonable request.

Abbreviations

IU:

Intolerance of Uncertainty;

IUS:

Intolerance of Uncertainty Scale

CFA:

Confirmatory Factor Analysis

CFI:

Comparative Fit Index

TLI:

Tucker Lewis Index

RMSEA:

Root Mean Square Error of Approximation

DERS-36:

Difficulties in Emotion Regulation Scale-36

PEBS:

Perinatal Eating Behaviors Screening tool

EPDS:

Edinburgh Postnatal Depression Scale

PSS:

Perceived Social Status

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Acknowledgements

We would like to acknowledge Carly Salloway for her consultation with data quality checks. We would also like to acknowledge and thank all the people that participated in this study for taking time during their pregnancy to contribute to this research.

Funding

The study was supported in part by a University at Albany Faculty Research Award (awarded to J.M.H.).

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Authors and Affiliations

  1. Department of Psychology, University at Albany, State University of New York, Social Sciences, 1400 Washington Avenue, Social Sciences, 399, Albany, NY, 12222, USA

    Kayla Costello, Drew Anderson & Julia M. Hormes

  2. Eating Disorder Assessment and Treatment Program, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    C. Alix Timko

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  1. Kayla Costello
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  2. C. Alix Timko
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  4. Julia M. Hormes
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Contributions

KC: data analysis and interpretation, manuscript preparation, study concept and design; C.A.T: data acquisition, study concept and design, and manuscript revisions; D.A.: manuscript revisions; J.H.: data acquisition, study concept and design, supervision, funding acquisition, project administration, and manuscript revisions.

Corresponding author

Correspondence to Julia M. Hormes.

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Ethics approval and consent to participate

All study procedures were approved by the Institutional Review Board at the University at Albany, State University of New York in accordance with the Helsinki Declaration. The Institutional Review Board granted a waiver of signed informed; all participants reviewed an informed consent form and indicated their consent to participate in the research by completing the study questionnaires.

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The authors declare no competing interests.

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Costello, K., Timko, C.A., Anderson, D. et al. Validation of the intolerance of uncertainty scale-12 in a sample of pregnant people. BMC Pregnancy Childbirth 25, 363 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07434-1

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BMC Pregnancy and Childbirth

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