To our knowledge, this study is the first to explore the relationships among MHL, FF, SE and AD in pregnant women. First, we developed a more comprehensive model on the basis of previous work[24, 49, 50]. Second, we examined the potential mechanisms and interactions among these factors via an SEM. We found that MHL, FF and SE had a negative impact on the development of AD in pregnant women. Therefore, this study opens a new door for improving AD in pregnant women, emphasizing the role of MHL, SE, FF and other factors. We also illustrated how closely these variables relate to AD in pregnant women.
In this study, the prevalence of AD was 31.90%, which is far higher than that reported in a previous study in this area (5.19%)[5], slightly higher than that reported in a multisite survey in China (28.4%)[7], and higher than that reported in a previous meta-analysis, which reported a pooled prevalence of 16.4% [3]. However, the prevalence was lower than that reported by some studies, such as those in India and Ghana[51, 52]. The reasons might be differences among study populations, regions, study periods and the measurement tools adopted[5]. A review reported that the prevalence of depression increases significantly after major public health emergencies[53]. AD is associated with a range of negative outcomes[9–14], which highlights the importance of timely identification and effective intervention for AD.
Compared with MHL and SE, FF was directly negatively correlated with AD and indirectly affected AD through SE, with the largest total effects. The model revealed that pregnant women with lower FF scores were more likely to have AD, which was consistent with other studies[9, 50]. Good family functioning makes it easier for pregnant women to obtain help and support in material and mental aspects. When pregnant women encounter difficulties, their family members can provide a stable rehabilitation environment. Some studies have noted that good family relationships can effectively reduce the discomfort caused by pregnancy, increase the positive emotions of pregnant women, and thus reduce the occurrence of AD[50]. Family members, as the largest source of social support for pregnant women, especially spouses, can effectively alleviate anxiety and depression in pregnant women[54, 55]. Therefore, during pregnancy, medical staff should encourage pregnant women to communicate with family members, guide pregnant women to actively express their physical and psychological discomfort, and make family members fully aware of the impact of family affection on the mental health of pregnant women, increasing the support that pregnant women receive from their families. In addition, greater perceived family support tends to bolster confidence and a sense of control, thereby strengthening pregnant women’s SE in coping with stressful events. This study also revealed that SE plays a mediating role in the relationship between FF and AD, indicating that FF can reduce depressive symptoms by enhancing SE. Relevant studies have shown that a healthy family with optimal functioning is supported by its members and that SE can generally be enhanced through social support [56].
Many studies have shown a significant negative correlation between SE and AD[16, 50], and the same conclusion was reached in this study. SE is an intrinsic personality trait that is associated with a high confidence level[57]. Pregnant women with high SE can actively face stressful events in life, which is more advantageous for enhancing SE to effectively regulate emotions and prevent depressive symptoms. SE is an important predictor of emotional responses, choice behaviors and thought patterns[58]. Therefore, based on this model, SE, as a modifiable factor, should be enhanced through effective intervention measures to create opportunities and enhance the ability of pregnant women to cope with mental health issues. SE is a key component of any educational intervention to address AD.
HL is a factor that contributes to enhanced SE. MHL can increase SE in pregnant women, which can affect depression. This hypothesis was supported in our study. Specifically, there was a significant positive correlation between MHL and SE. The higher MHL was, the stronger SE was. This finding aligns with those previously reported[24, 59]. On the other hand, there was a significant negative correlation between SE and depressive symptoms. The higher SE was, the lower the degree of depressive symptoms, which is consistent with previous studies[22–24]. In other words, MHL can influence depressive symptoms through the mediating effect of SE. In addition, this study revealed that pregnant women with adequate HL had a lower risk of depressive symptoms, which is consistent with the conclusions of previous studies[31, 32]. Each unit increase in the HL score was associated with a 4–5% reduction in the likelihood of developing depression[60], highlighting the protective effect of HL against depression. This might be because individuals with a higher level of HL can realize their own emotional problems when they experience negative emotions and actively obtain health information or receive help from medical service organizations to deal with their emotions in a positive way, which prevents the occurrence of depressive symptoms. This has also been confirmed in relevant studies; that is, HL can regulate the desire of individuals to seek help, thereby controlling the development of psychological problems[61]. Therefore, medical staff can actively improve the HL level of pregnant women and enhance their SE through various measures to prevent prenatal depression.
In our study, there was no significant relationship between MHL and FF. This finding was inconsistent with the results of other related studies[62, 63]. The HL and good FF scores were higher in the group without family dysfunction than in the group with family dysfunction[62], possibly because the support of pregnant women mainly comes from cooperation between family members, who explore solutions to related problems and support each other to develop good HL. However, in our study, FF had no significant effect on MHL. This might be because MHL reflects pregnant women’s knowledge of nutrition, safety, first aid, and medicine, which is acquired from medical professionals, while most family members have no medical background[64]. There are few studies on MHL and FF. Therefore, we will continue to explore the relationships between MHL and FF in future studies.
Strengths and Limitations
This study included pregnant women from 6 hospitals in the central urban area and surrounding urban areas in Chongqing for the first time, and the research results are representative of Chongqing. Currently, many variables associated with AD in pregnant women are being studied, including MHL, SE and FF. This is the strength of this research. In addition, for the first time, we established the relationships among these variables, which can provide a theoretical basis and intervention ideas to improve AD in pregnant women. Our study has several limitations. First, causal relationships among MHL, SE, FF and depression could not be inferred from this cross-sectional study. In the future, longitudinal studies can be designed to explore causality. Second, the variables were mainly measured via self-report questionnaires, which may be influenced by social desirability. Third, the accuracy of the participants’ answers may have been affected by the length of the research questionnaire items. Therefore, shorter forms of these questionnaires should be used in future research.