LITHUANIAN UNIVERSITY OF HEALTH SCIENCES ACADEMY OF MEDICINE
FACULTY OF PUBLIC HEALTH
Kyunghee Tark
THE IMPORTANCE OF SOCIAL SUPPORT
FOR EMOTIONAL WELLBEING OF WOMEN DURING PREGNANCY Master Thesis (Public Health)
Kyunghee Tark Assoc. prof. Giedrė Širvinskienė
KAUNAS, 2019
SUMMARY Master in Public Health
IMPORTANCE OF SOCIAL SUPPORT FOR EMOTIONAL WELLBEING OF WOMEN DURING PREGNANCY
Kyunghee Tark
Giedrė Širvinskienė, Assoc. Professor
Department of Health Psychology, Lithuanian University of Health Sciences.
Kaunas; 2019. 53 p.
Introduction. It was reported that insufficient social support during pregnancy deteriorates the psychological health of pregnant women negatively affects her quality of life. Despite the high prevalence of depression during pregnancy, this is a relatively underexplored area in Lithuania.
Furthermore, the awareness of the importance of social support for the emotional wellbeing of pregnant women should be emphasized.
Aim of the work. The present study aims to explore the importance of social support for the emotional wellbeing of women during pregnancy.
Objectives. There are 3 objectives: 1) To describe social support situation of pregnant women, 2) To evaluate the emotional wellbeing of pregnant women, 3) To analyse the association between social support and emotional wellbeing during pregnancy.
Methods. It is a cross-sectional study with a sample of pregnant patients. 270 questionnaires were distributed, and 208 respondents (pregnant women) have returned correctly filled in a survey (response rate: 77%). The questionnaire was comprised of 44 questions was conducted in Lithuanian, which included The Edinburgh Depression Scale (EPDS), The Multidimensional Scale of Perceived Social Support (MSPSS), and questions about sociodemographic characteristics and feeling and thought.
Results. High depressiveness was characterized for 18.3 % of pregnant women. There is a correlation of depression with perceived social support (p<0.001) and there is also a correlation of emotional status with perceived social support (p=0.001). Women who had lower social support more often experienced depressiveness and worse emotional status. In addition, women who had more children reported less social support (p=0.01).
Conclusions. There is a significant correlation between the social support given during pregnancy and increased emotional wellbeing of pregnant women.
Practical recommendations. It is recommended to provide screening for women emotional state and need for counselling in antenatal programs, especially for those women who have poor social support.
Keywords. social support; emotional wellbeing; depression; pregnant women
SUMMARY IN LITHUANIAN Visuomenės sveikatos magistras
SOCIALINĖS PARAMOS SVARBA MOTERŲ EMOCINEI GEROVEI NĖŠTUMO METU Kyunghee Tark
Giedrė Širvinskienė, doc. Profesorius
Lietuvos sveikatos mokslų universiteto Sveikatos psichologijos katedra.
Kaunas; 2019. 53 p.
Įvadas. Tyrimai rodo, kad nepakankama socialinė parama nėštumo metu blogina nėščių moterų psichologinę sveikatą, kuri neigiamai veikia jos gyvenimo kokybę. Nepaisant didelio depresijos paplitimo nėštumo metu, tai yra palyginti mažai ištyrinėta sritis Lietuvoje. Be to, reikia pabrėžti, kad socialinė parama yra vienas iš svarbiausių nėščių ir pagimdžiusių moterų emocinės gerovės veiksnių.
Darbo tikslas. Šiuo tyrimu siekiama ištirti socialinės paramos svarbą emocinei moterų gerovei nėštumo metu.
Uždaviniai. 1) Apibūdinti nėščių moterų socialinės paramos situaciją, 2) Įvertinti nėščių moterų emocinę gerovę, 3) Išanalizuoti sąsajas tarp socialinės paramos ir emocinės gerovės nėštumo metu.
Metodai. Tai yra vienmomentinis nėščių pacienčių tyrimas. Buvo išdalinta 270 klausimynų, 208 respondentės (nėščios moterys) sugrąžino teisingai užpildytas anketas (atsako dažnis - 77%).
Klausimyną sudarė 44 klausimai lietuvių kalba, įskaitant Edinburgo depresijos skalę (EPDS), daugialypės suvokiamos socialinės paramos skalę (MSPSS) ir darbo autorės parengtus klausimus apie emocinę būklę ir sociodemografines charakteristikas.
Rezultatai. Aukštas depresiškumas buvo būdingas 18.3 proc. moterų. Nustatytos sąsajos tarp moterų depresiškumo ir suvokiamos socialinės paramos (p <0.001), taip pat egzistuoja emocinės būklės ir suvokiamos socialinės paramos koreliacija (p = 0.001). Moterys, turinčios mažesnę socialinę paramą, dažniau patyrė depresiją ir blogesnę emocinę būklę. Be to, daugiau vaikų auginančios moterys nurodė turinčios mažiau socialinės paramos (p = 0.01).
Išvados. Mažesnė socialinė parama nėštumo metu susijusi su didesniu moterų depresiškumu bei blogesne emocne būkle.
Praktinės rekomendacijos. Rekomenduojama atlikti moterų emocinės būsenos patikrinimą ir pagalbos poreikius teikiant sveikatos priežiūros paslaugas nėščioms moterims, ypač toms moterims, kurios turi nepakankamą socialinę paramą artimoje aplinkoje.
Raktiniai žodžiai. socialinė parama; emocinė gerovė; depresija; nėščios moterys
ACKNOWLEDGEMENTS
First, I would like to thank my supervisor, Giedrė Širvinskienė, who has taught me throughout this entire process of writing this thesis. In addition, I really appreciate the advice from the head of Department of Obstetrics and Gynecology, prof. Rūta Nadišauskienė, and midwife Asta Kirkilytė.
Without their support, it would have been impossible to properly manage this thesis project. I also would like to thank Dr. Rima Kregždytė for her guidance. Finally, I wish to thank all of the women who participated in my study.
TABLE OF CONTENTS
ABBREVIATIONS ...8
INTRODUCTION ...9
AIM AND OBJECTIVES OF STUDY ... 11
1 LITERATURE REVIEW ... 12
1.1 The social support for pregnant women ... 12
1.2 The emotional wellbeing of pregnant women ... 15
1.3 Association between social support and emotional wellbeing... 19
2 MATERIAL AND METHODS ... 21
3 RESULTS ... 24
3.1 Sociodemographic Characteristics ... 24
3.1.1 Age of respondents ... 24
3.1.2 Marital status ... 24
3.1.3 Distribution of women by the first pregnancy ... 25
3.1.4 Stage in the pregnancy ... 26
3.1.5 The number of children... 26
3.1.6 Working situation ... 27
3.1.7 Education of respondents ... 27
3.1.8 Financial situation ... 28
3.2 Social support during pregnancy ... 29
3.3 The emotional wellbeing of pregnant women ... 33
3.3.1 Depression ... 33
3.3.2 Emotional Status... 36
3.4 Association between social support and emotional wellbeing during pregnancy .. 38
4 DISCUSSION ... 39
CONCLUSIONS ... 44
PRACTICAL RECOMMENDATION ... 46 REFERENCE ... 47 ANNEX ... 54
LIST OF TABLES
Table 3.1. 1 Distribution of women by age ... 24
Table 3.1. 2 Distribution of women by marital status ... 25
Table 3.1. 3 Distribution of women by the first pregnancy ... 25
Table 3.1. 4 Distribution of women by pregnancy trimester ... 26
Table 3.1. 5 Distribution of women by the number of children ... 26
Table 3.1. 6 Distribution of women by working status ... 27
Table 3.1. 7 Distribution of women by education ... 28
Table 3.1. 8 Distribution of women by financial status... 28
Table 3.2. 1 Distribution of women by the level of perceived social support ... 29
Table 3.2. 2 Relationship between the number of children and social support (all dimensions) ... 30
Table 3.2. 3 Distribution by the association between perceived social support and marital status (significant others subscale) ... 31
Table 3.2. 4 Relationship between the number of children and social support (significant others subscale) ... 31
Table 3.2. 5 Relationship between the number of children and social support (family dimension) .. 32
Table 3.3. 1 Distribution of participants by depression level ... 33
Table 3.3. 2 Association between depression and age (Chi-square test) ... 33
Table 3.3. 3 Association between Depression and Marital Status of Participants ... 34
Table 3.3. 4 Association between depression and the number of children... 34
Table 3.3. 5 Distribution of participants by the level of emotional status ... 36
Table 3.3. 6 Association between emotional status and marital status ... 37
Table 3.3. 7 Association between emotional statements and financial situation ... 37
Table 3.4. 1 Nonparametric correlation between depression and social support, emotional status and social support ... 38
ABBREVIATIONS MSPSS - The Multidimensional Scale of Perceived Social Support EPDS - Edinburgh Postnatal Depression Scale
INTRODUCTION
Many pregnant women have unstable emotions because of changes in hormone levels, a great number of changes in physical appearance, and fears and worries concerning the childbirth. It is often reported that their emotions swing up and down without any reason. It is therefore important to positively control women’s emotions and keep them in proportion. It is also crucial to address depression, which is one of the health problems frequently associated with pregnant. Depression should be carefully considered, diagnosed early and treated as soon as possible because it hurts the wellbeing of pregnant women (1). Depression contributes to poor emotional functioning, which has been associated with an increase in prenatal visits, fetal surveillance and resource use (2). Thus, it is necessary to be knowledgeable of the importance in dealing with depression and the emotional status of pregnant women.
Generally, social support is described as financial, emotional, and mental support given to someone by family, friends, relatives or specific others. Social support positively and directly affects one’s health whether there is stress or not and protects psychological wellbeing by decreasing or balancing the damage (3). Social support could be one of the largest factors in the emotional wellbeing of pregnant women. It was reported in the literature that social support has a positive effect on psychological wellbeing (4). The lack of a relationship between a pregnant woman and her partner has been found to create financially and caregiving strain, resulting in psychological distress and anxiety in pregnant women (4, 5). Other types of social support have been found to benefit the wellbeing of pregnant women by providing childcare and personal advice (6, 7). Regardless of the differences, it is agreed in the literature that one should emphasize the importance of social support for the well-being of women during pregnancy, as it provides a sense of control over the situation, greater satisfaction with life, and also contributes to low levels of depression and anxiety (8, 9). Insufficient social support during pregnancy deteriorates the psychological health of pregnant women negatively affects her quality of life, has a poor effect on eating habits, and leads to an increase in the use of alcohol, smoking, and substance use (3, 10).
Depression can be prevented and treated if health care professionals can detect the factors that increase the risk of depression during pregnancy as early as possible. However, despite the high prevalence of depression during pregnancy and their significant negative impact, this is a relatively underexplored area in Lithuania. Furthermore, the awareness of the importance of social support for the emotional wellbeing of pregnant women should be emphasized.
The present study aims to examine the importance of social support for pregnant women, the correlation between social support, depression, and emotional wellbeing, and how social support affects the emotional wellbeing of pregnant women in Kaunas, Lithuania.
AIM AND OBJECTIVES OF STUDY
Aim:
To explore the importance of social support for the emotional wellbeing of women during pregnancy.
Objectives:
(1) To describe social support situation of pregnant women.
(2) To evaluate the emotional wellbeing of pregnant women.
(3) To analyse the association between social support and emotional wellbeing during pregnancy.
1 LITERATURE REVIEW
1.1 The social support for pregnant women
Social support refers to the emotional and material resources that are provided to an individual through the interpersonal communication (11). It is an exchange of resources between at least two individuals; resources perceived by the provider or the recipient to be intended to promote the health of the recipient (12). Thoits (2010) provided a more comprehensive definition of social support that refers to emotional, informational, or practical assistance from significant others, such as family members, friends, or co-workers, and that support actually may be received from others or perceived to be available when people needed (13).
In epidemiologic studies, social support measures have often focused either on: 1) structural measures, which means the size of social relationships or social network or 2) functional measures of an individual's perception of support available or support received. Early studies evaluated social support by quantifying and summarising social relationships, such as marital status, religion, and the number of close friends or relatives (14, 15).
Social relationships perform an essential role in promoting better health and reducing diseases.
However, not all relationships were supportive. They do not always have improved health outcomes.
Many researchers recognised that structural aspects of social networks, such as the number of social contacts, do not necessarily translate to more received support (16). In contrast, functional measures of social support can assess an individual's perception of the social support she receives or may receive in a time of need.
House and Kahn (1985) recommended that researchers have to estimate all levels of social support, including social relationships, social networks, and received social support (sub-divided into types of support such as emotional, informational, and instrumental (17). Berkman et al. (2000) argued for an even larger conceptual model of the role of social support on health. They suggested that the effect of social support have to be seen as a multi-level process starting with the broader cultural context that shapes social networks which, in turn, influence health through social support, social influence, and access to material resources. Social support may influence health through behavioural, psychological, and physiological pathways (18).
Social support plays a major role in maternal factors. Pregnant women with low support reported increased depressive symptoms and reduced quality of life (19). Several theories and relationships have been proposed regarding the interaction of social support on pregnancy outcomes.
Social support influenced the pregnancy outcome by countering the effects of stress or by directly improving a woman’s mental health (20). Besides, the perceived social support in the first pregnancy was found to be associated with childbirth satisfaction (21). Thus, for women, social support is a valuable resource and can affect their reactions to pregnancy.
How might social support promote maternal and infant health? Over the past 40 years, It has become increasingly accepted that social support can have a positive effect on a wide variety of health outcomes, including pregnancy. According to a study conducted by Ilnaz Iranzad (2014), There was a correlation between stress and social support. This study was a cross-sectional study on 450 pregnant women referred to health centres of Tabriz University of Medical Sciences, from October 2012 to May 2013. The demographics questionnaire, Interpersonal Support Evaluation List (ISEL) and Perceived Stress Scale (Ten-item PSS) were used to collect the information. The study showed that the rate of social support for pregnant women was relatively high, and there was a negative correlation between the level of social support and perceived stress. Considering that, mothers with undesirable social support may experience more stress in their life and consequently, the risk of mental disorders and unwanted pregnancy and childbirth outcomes increases in these mothers (22). It has been approved that expecting mothers who have benefited from the social support of their partner, family, and even co-worker during pregnancy are less likely to get suffered from peripartum complications. For example, pregnant mothers who have been well supported by their family would be less often affected by mental problems, such as distress, anxiety disorders and depression, which reaches in absolutely less preterm labour (23).
The R. Jay Turner (1990) study presented information on the role and significance of social support for the occurrence of health and birth problems among adolescent mothers and their babies.
268 Pregnant teenagers were interviewed during pregnancy and again approximately four weeks after delivery, and hospital records were collected. The significance of the family, friends, and partner support during the pregnancy were examined concerning infant and mother outcomes assessed at or after birth (24). Although social support should be valuable to all expectant mothers, life circumstances may place some women in greater need than others. For example, adolescents, unmarried women, and women with few economic resources may be especially likely to benefit from support. Pregnancy is not uniformly stressful for all women, and there is growing evidence that women with exceptionally high prenatal stress are at greater risk for poor outcomes (24, 25).
Moreover, the maternal-fetal attachment has a significant effect on the health of women and their infants (26), which shows the importance of emphasising the maternal-fetal relationship during pregnancy. Social support is one of the issues that probably affect maternal-fetal attachment (27).
According to Mina Delavari et al. (2018), they found a significant relationship between maternal-fetal attachment, depression and social support. They recommended devising plans for increasing the support given to women and improving the society's and families' awareness about these issues in the attempt to promote healthy mothers and thereby healthy families and communities (28). Besides, higher social support is associated with a better quality of diet, which in turn affects fetal growth and pregnancy outcome (29).
1.2 The emotional wellbeing of pregnant women
Emotional wellbeing refers to the emotional quality of an individual's experience in every single day - the frequency and intensity of experiences of joy, stress, sadness, anger, and affection that make one's life pleasant or unpleasant. Moreover, Huppert (2009) referred that psychological wellbeing can be seen as a combination of feeling good (happy, content, interested, engaged, confident and showing affection for others) and being able to function effectively (developing one’s potential, having some control over one’s life, a sense of purpose, experiencing positive relationships) (30).
The time directly after confirmation of pregnancy is associated with a specific swing of emotions – in many women, there arises tension which maintains itself until the first visit to a physician. Many ambivalent feelings occur, which depend on the fact whether the pregnancy was planned or not, whether this is the first or a subsequent pregnancy, if the woman has a permanent life partner, or if her state of health does not require constant administration of certain drugs which may affect the development of the fetus (31).
The perinatal period is recognised as a time of major transition that can be extremely emotional (32), and associated with significant distress (33). Symptoms of emotional distress are experienced by a substantial number of women, with international research indicating that depression affects approximately 10–25% of women, while anxiety affects approximately 25–45%
of perinatal women (34, 35). The negative consequences of perinatal distress have been well documented and extend not only to the new mother, but also her fetus, child, partner, and family.
There was increasing evidence that positive mental wellbeing leads, on an individual level, to a more flourishing school, work and home life and this, in turn, brings benefits for the broader community as a whole. Improved psychological wellbeing was also associated with physical health benefits (36).
Prevalence of fear of pregnancy and childbirth
Pregnancy is an emotionally unstable period, even though it is the happiest period in life for women. Fear of pain is often reported as the reason for fearing delivery. Over 20% of pregnant women have had fear and 6% of women reported that it is disabling. 13 % of non-pregnant women have reported fear of childbirth, which made them to postpone or avoid pregnancy (37). In addition, fear of childbirth might be double in the third trimester. This specific fear and anxiety of death
during childbirth lead to a phobic state called “tokophobia”, which might affect women starting in their childhood. Tokophobia is a significant fear of childbirth, especially when women request an elective cesarean section. Fearful women with free access to analgesic drugs during labour were still more likely to experience childbirth negatively and suffer severe emotional imbalance postpartum.
Approximately 6 - 13% of pregnant women experience severe and debilitating fear, which, in addition to physical outcomes, can result in psychological complications such as depression and anxiety, negative mood after childbirth, eating disorders (38), and even uninformed selection of delivery method. It has been proven that fear of childbirth was major in the selection of cesarean section by Iranian women (39). Based on the statistics reported by the World Health Organization (WHO), the prevalence of cesarean section was 46% in Iran in 2014, however, the recommendation of the WHO for an acceptable prevalence of cesarean section by 2014 was a maximum of 5–15%
(40).
Prevalence of anxiety of pregnancy and childbirth
Anxiety in pregnancy and childbirth have harmful effects, and in the long-term anxiety by stimulating the autonomic nervous system, smooth muscles of arteries constrict and Uterus-placenta blood flow and oxygen supply to the uterus drop; and as a result, fetal heart rate pattern become abnormal and the risk of preterm delivery could be increased (41). Moreover, anxious and depressed mothers are not sensitive to the messages conveyed by their children (42).
The prevalence of anxiety disorders may also have opposite effects on results of obstetric, fetal and neonatal (43). It is also notable to mention that mental health problems during pregnancy have been studied in 90% of high-income countries; unfortunately, while compared only 10% of low and middle-income countries have available information (44).
In humans, an association between the mother's emotional state and the behaviour or heart rate of her fetus is supported by competent evidence. Monk et al. for example, have conducted experiments in which a pregnant mother is asked to carry out a stressful computer task, while the fetal heart rate is monitored (45). They showed that the fetal heart rate went up during the task, but only in the mother's, who rated themselves as anxious. Thus, even before birth, the fetus can be affected by the maternal emotional state. Also, Maternal relaxation has also been shown to improve indices of fetal neurobehavior, such as heart rate variability (46).
Effect of depression during pregnancy
Transitioning into motherhood can render women more vulnerable to anxiety and depressive symptoms. Prevalence of Postpartum Depression (PPD) varies across and within countries from 0 to 15% in some high-income countries to 10–60% in low-income countries (47). Frequency of depression, particularly during the second and third trimesters of pregnancy, are substantial (48).
Depressive outlooks also have adverse physical effects on infants that appear to increase the risk of preterm births or low birth weight, as well as negatively impact the mother's relationships.
Many negative child outcomes have been associated with being born to a mother who experienced depression and anxiety during pregnancy or in the postpartum period. Unfortunately, few mothers are diagnosed which may lead to chronic depression and a disturbed mother-infant relationship. It is especially true for developing countries where mental health remains a stigma and is not covered by most insurance programs or governmental agencies (49).
According to the newest article about between pregnant women and depression, Women who exhibit optimism in the antepartum period appear to be at a decreased risk of postpartum depression.
This can have great benefits not only for women faced with the possibility of postpartum depression, but also for their babies, families, and relationships (50).
Effect of stress during pregnancy
Psychological distress during pregnancy is associated with a higher risk of behavioural and emotional problems, such as attention deficit hyperactivity disorder (ADHD), autism, and affective disorders in the offspring (51). At birth, an increase in congenital malformations is associated with severe stress in the first trimester, such as the death of an older child (52). Many studies have shown that less severe stress is associated with somewhat lower birthweight and reduced gestational age.
King and Laplante (2005) found even more significant effects on cognitive ability. They examined 2-year old children of mothers who had been exposed to a Canadian Ice storm during pregnancy and compared the outcome for those who had been exposed to high or low stress. The findings from Project Ice Storm strongly suggested that a major stressful event, independent of maternal personality factors, can harm cognitive and language development of the unborn child.
Other results also demonstrated significant harmful effects of the severity and timing of prenatal
maternal stress on perinatal outcomes, infant personality, behavioural and emotional functioning, and even physical development of children. Furthermore, a study has found several effects that are related to the timing of the stressor, with a particular emphasis on the 2nd trimester (53).
Care for the emotional state of pregnant women remains an overlooked aspect of obstetric medicine. Many studies have shown that, if a mother is depressed, anxious, or stressed during pregnancy, this increases the risk for her child to have a wide range of adverse outcomes, including emotional problems, symptoms of attention deficit hyperactivity disorder, or impaired cognitive development (54). It is still true that most depression, anxiety, and emotional and physical abuse experienced by pregnant women is undetected by health professionals, and little help seems to be available. Symptoms of anxiety and depression are at least as common during pregnancy as postnatally (55).
1.3 Association between social support and emotional wellbeing
Indeed, there are documents related to the power of social support in encouraging the emotional wellbeing of pregnant women that nobody can deny it. Especially during pregnancy, women are considered as an exposed group who experience various changes. Pregnancy is considered a time of significant life change requiring major psychological adjustments, often associated with anxiety and stress (56). Pregnant women have not only to experience physiologic and hormonal changes, but they are psychologically surrounded by the thinking that they may not be able to handle the upcoming new environment. For that reason, they are in significant need for social support to be enabled to control this situation.
In the United States, a study with pregnant women found that married women had more support than those unmarried and that partner support and marital stability are essential factors for health and wellbeing (57). It has been approved that expecting mothers who have benefited from the social support of their partner, family, and even co-worker during pregnancy are less likely to get suffered from peripartum complications. For example, pregnant mothers who have been well supported by their family would be less often affected by mental problems, such as distress, anxiety disorders and depression (23). In addition, few of them would experience post-partum depression- a state which may result in trouble for families. Furthermore, weaker social support has shown that less effective social support during pregnancy would end in a higher level of cortisol secretion.
Consequently, biological sensitivity to psychological distress would be increased. This potentially exposes the fetus to the harmful effects of cortisol (58). Psychosocial stress and poor social support are associated with low birth weight outcome (59). Babies born to women with low social support during pregnancy had reduced birth weight by 200 gm on average (19).
This study highlighted social factors contributing to the emotional wellbeing of Afghan mothers living in Australia. Participants consistently talked about the challenges associated with separation from their families, primarily their mothers and sisters, throughout the birth and post- birth period. Women discussed their experiences of lacking social support and the vast majority of women suggested that this contributed towards emotional difficulties in early motherhood.
Separation from these supportive relationships was understood as a source of tension, and many women described sadness and loss associated with their weak connection to female relatives (60).
Moreover, having a larger number of supportive persons during pregnancy helps protect against postpartum depression, and this effect is more significant in depressive than non-depressive pregnant women (61).
Another finding was that dissatisfaction with partner support in early pregnancy was associated with the women's emotional wellbeing, depressive symptoms, major worries and consideration of abortion. In addition, women who were dissatisfied with partner support were more likely to go through a divorce or separation during the first postpartum year. The finding that multiparous women more often experienced a lack of support may be explained by the heavy workload of household tasks and their previous experience of being a new mother. Earlier research suggested that co-parenting interventions might be of great value especially around the birth of the first child (62).
Women who were not living with a partner in early pregnancy were more likely to be dissatisfied with partner support, as were women whose pregnancy was unplanned or who had considered abortion. A relationship that starts with pregnancy could be more challenging than if a couple has been living together for several years and planned the pregnancy. It was also known that women and men have ambivalent feelings about pregnancy and could be unsure when they are ready to become a parent (63). A woman's ambivalence could also be affected by hormonal changes and the physical discomfort in early pregnancy as well as the partner's attitude to the pregnancy. A negative attitude is likely to result in less support which in turn prompts the woman to consider abortion, which is in line with previous findings (64).
Peer support is an area that has the potential to address some of the critical issues associated with poor perinatal mental health, such as weak social supports (65), reduced emotional support, and social isolation (66). Additionally, women experiencing emotional distress in the perinatal period have themselves expressed a preference for ‘talking therapies’, with the opportunity to discuss their feelings in depth and receive reassurance that other women experience similar challenges (67).
2 MATERIAL AND METHODS
Type of Research
It is a cross-sectional study with a sample of pregnant patients of the Department of Obstetrics and Gynaecology in Hospital of Lithuanian University of Health Sciences Kauno klinikos. The survey was conducted from October 2018 to December 2018.
Researched contingent/respondents
In total, 270 questionnaires were distributed, and 208 respondents (pregnant women) have returned properly filled in a questionnaire (response rate: 77%).
Sample of research and its formation method
According to the Lithuanian Medical data of Births, the total number of children born in Lithuania in 2017 was 26,940 (68). It is the newest statistic about childbirth in Lithuania available.
The possible sample size was calculated while planning the survey. In order to obtain the confidence level of 95% and the margin of error 7%, it was necessary to survey at least 196 women.
The questionnaires were given to pregnant women during their stays at the hospital or during visits at the Department of Obstetrics and Gynaecology with the request to answer them.
Research instruments and variables
The questionnaire was used for data collection: The Edinburgh Depression Scale (EPDS), Multidimensional Scale of Perceived Social Support (MSPSS), 8 questions about sociodemographic characteristics, 12 questions about feeling and thought in the past 7 days and 2 questions about whether a woman has someone who helps her. The questionnaire was comprised of 44 questions and was conducted in Lithuanian. Participants were asked to complete a survey which included multiple choice, Likert-scale, and closed-ended questions.
The Edinburgh Depression Scale is widely used for postpartum depression screening.
However, EPDS is also a reliable instrument for screening depression during pregnancy (69).
Maternal depressiveness was measured based on the Lithuanian version of EPDS (70). The EPDS is a 10-item questionnaire that asks about depressive symptoms, specifically how they have been feeling in the past seven days. Items on the questionnaire include: "I have been anxious or worried
for no good reasons”, and "I have been able to laugh and see the funny side of things”. Responses are scored 0, 1, 2 and 3 based on the seriousness of the symptom. Items 3, 5 to 10 are reverse scored (i.e., 3, 2, 1, and 0). The overall assessment is done by total score, which is determined by adding together the scores for each of the 10 items. Two groups were defined according to the cut-off scores of EPDS: women who scored 11 points and below were attributed to the low level of depressiveness group, and women who scored 12 and above were attributed to the high level of depressiveness group (71).
The social support was measured using MSPSS, which asks respondents to rate how much social support they had experienced and how they feel during pregnancy. The MSPSS is a 12-item tool that evaluates perceived social support in the three dimensions of a family (questions 3, 4, 8, 11), friends (questions 6, 7, 9, 12), and specific individuals (questions 1, 2, 5, 10), including: "My family really tries to help me", "I have friends with whom I can share my joys and sorrows", and
"There is a special person who is around when I am in need". This tool is scored based on the seven-point Likert scale (very strongly agree = 7; strongly agree = 6; mildly agree = 5; Neutral = 4;
mildly disagree = 3; strongly disagree = 2; very strongly disagree = 1). The minimum and maximum obtained scores of the MSPSS are, respectively, 12 and 84, and higher scores represent higher social support. The validity and reliability of the MSPSS were reported for the first time by Zimet et al. (Cronbach's alpha 0.88)(72).
The sociodemographic characteristics also were included in the questionnaire regarding age, marital status, the number of children, employment status, the level of education, whether it is a first-time pregnancy, financial status, and pregnancy stage.
Emotional status in the past 7 days was estimated using the following 12 questions ; “I feel happy about this pregnancy”, “Sometimes I feel it is difficult to sleep", "I am feeling good about myself", "I am feeling hopeless about the future", "I have the energy to spare with others", "I can deal with problems well”, “I feel lonely”, “I have been feeling confident”, “I have been feeling close to other people”, “I have been feeling loved”, “I have been interested in new things”, and
“Sometimes, I feel anger at small things”. It is scored based on the five-point Likert scale (Always = 5; Often = 4; Sometimes = 3; Rarely= 2; None = 1). The minimum and maximum obtained scores are 12 and 60, and a 36/48/60 cut-off was used, as women who scored 36 points and below were attributed to the poor emotional status group, and the moderate emotional status group represented women who scored between 36 and 48, and above 49 to 60 were attributed to the healthy emotional status group.
Besides, perception of availability of social support was estimated using the following 2 questions: Q1) whether women have someone who understands and helps them when they need help? (the possible answer is Yes or No), and if you have someone, how many people do you have?
(Participants could write the number of people), and Q2) Who are they? Participants could choose multiple answers among 1) Husband/Partner, 2) Parents, 3) Relatives, 4) Friends 5) Neighbors, 6) Others. If participants chose the Others category, they could write who provided support.
According to the answers, the participants were divided into 4 groups: lacking social support (did not indicate a single person to whom a participant could appeal while experiencing difficulties and feeling bad), receiving low support (1–2 people), moderate support (3–5 people), and high support (6 and more people).
Methods of data analysis
Data were analyzed using a quantitative method. Statistical analysis was performed with SPSS version 25 and MS Excel which were used for visual presentations of results. Chi-square test was used to evaluate the association between demographic characteristics and grouped depression, social support or emotional well-being scores. Association between ordinal variables (social support, depression, emotional status) was evaluated by Spearman’s correlation coefficient because the variables were not normally distributed.
Research ethics
Ethics approval for the study was provided by the Centre of Bioethics of Lithuanian University of Health Sciences. Written informed consent for participation in the questionnaire survey was obtained from pregnant women. Additionally, permission to conduct research from the clinic or hospital was received No. BEC-vs(M)-26.
3 RESULTS
3.1 Sociodemographic Characteristics
3.1.1 Age of respondents
Table 3.1.1 presents the distribution of ages for women in this sample. The age of respondents ranged from 17 to 44 years, with a mean age of 30.12 years. The data was analysed to recognise the distribution of pregnant women by age. It was seen that women who were between the ages of 26 and 34 years old formed the maximum percentage of the sample population.
Table 3.1. 1 Distribution of women by age
Age Number of women %
25 36 17.3
26-34 131 63.0
35 41 19.7
Total 208 100.0
3.1.2 Marital status
The majority of respondents were married (n=151, 72.6 %), and approximately one-fourth of the sample were living with a partner (n=48, 23.1 %). Six respondents were divorced or separated.
In the questionnaire, there were 6 categories of marital status. However, only two women answered in single, or a woman checked in other. For a more accurate analysis, the number of them was not included.
Table 3.1. 2 Distribution of women by marital status
3.1.3 Distribution of women by the first pregnancy
Table 3.1.3 shows the proportion of the number of women were almost evenly distributed by whether first pregnancy. 90 women answered that it is the first pregnancy and 109 women responded that it is not the first pregnancy.
Table 3.1. 3 Distribution of women by the first pregnancy
Number of women %
First pregnancy
YES 99 47.6
NO 109 52.4
Total 208 100.0
Marital status Number of women %
Living with a husband 151 72.6
Living with a partner 48 23.1
Divorced or separated 6 2.9
Single (Not married) 2 1.0
Other 1 0.5
Total 208 100.0
3.1.4 Stage in the pregnancy
As can be seen, almost 90% of women were in the third trimester who were between 13 weeks and 26 weeks (Table 3.1.4). About 10% of women were in the 2nd trimester. A major limitation of this study was a lack of diversity because none of the pregnant women was in the first group.
Table 3.1. 4 Distribution of women by pregnancy trimester
3.1.5 The number of children
There is a question which asked how many children you have. Over half of the women answered that I do not have a child. About one-third of women have a child. In this study, 3 groups are depending on the number of children. Women who do not have a child is in the first group, women who have a child is in the second group, and women who have two children or more is in the third group.
Table 3.1. 5 Distribution of women by the number of children
Number of women %
The number of children
None 114 54.8
One 65 31.3
Two or more 29 13.9
Total 208 100.0
Number of women %
Trimester
13 - 26 weeks 21 10.1
27 weeks - birth 187 89.9
Total 208 100.0
3.1.6 Working situation
According to Table 4.1.4, almost half of women answered that they are not in work at the time of the survey, at 45.7% while 17.3% of women were in work but were on maternity leave. Just over one-third of women are still working during pregnancy, at 36.5%.
Table 3.1. 6 Distribution of women by working status
Number of women %
JOD
Employed 76 36.5
Unemployed 95 45.7
Maternity leave 36 17.3
Total 207 99.5
No answer 1 0.5
Total 208 100.0
3.1.7 Education of respondents
In the original questionnaire, there were 3 categories which are 1) those who did not complete secondary education, 2) those who completed secondary education and who did not finish higher education, and 3) those who completed higher education. However, a very small number of women answered in the first category. Thus, the first and the second group were combined to refer to women who have no higher education. The majority of women have finished higher education, at 65.4%, which is approximately two thirds. The percentage of women who did not finish higher education is just over one third, at 34.6%.
Table 3.1. 7 Distribution of women by education
Number of women %
Education
Lower than higher 72 34.6
Higher 136 65.4
Total 208 100.0
3.1.8 Financial situation
What is noticeable is that by far the highest number of women reported that their financial status was average compared to other households in Lithuania, with this figure standing at 81.7 %.
In contrast, 17.3 % of women stated that their financial situation was above average. In this study, only one woman responded that her financial status was below the average, and two women did not answer this question; thus three women were excluded from the analysis.
Table 3.1. 8 Distribution of women by financial status
Number of women %
Financial status
Average income families 170 81.7
Higher income families 36 17.3
Below average income families 1 0.5
No answer 3 1.5
Total 208 100.0
3.2 Social support during pregnancy
Women were divided into 3 groups according to the total score divided by 12. The first group with scores between 1 and 2.9 is evaluated as receiving low support, and the second group with scores from 3 to 5 seem to receive moderate support. The third group from 5.1 to 7 can be evaluated as having active social support to the third group. As seen table 5.4.1 almost all of the 208 people were rated as having high social support(n=197). Very few women(n=3) were found to have very low social support during pregnancy.
Table 3.2. 1 Distribution of women by the level of perceived social support
Number of women %
Level of perceived social support
Low support 3 1.4
Moderate support 8 3.8
High support 197 94.7
Total 208 100.0
The demographic characteristics were analysed in terms of perceived social support and it was found that the perceived social support shows a correlation with the number of children (Table 3.2 2). The number of children was associated with the level of perceived social support to women during pregnancy. A group with higher social support was women without children. Among the women who did not have children, over 98% of women surveyed were rated as having high social support. In addition, a woman with two or more children was found to receive less social support compared to a woman who has one child.
Table 3.2. 2 Relationship between the number of children and social support (all dimensions)
The number of children None One Two or more Total
Level of perceived social
support
Low N (%) 1 (0.9) 1 (1.5) 1 (3.4) 3 (1.4)
Moderate N (%) 1 (0.9) 2 (3.1) 5 (17.2) 8 (3.8) High N (%) 112 (98.2) 62 (95.4) 23 (79.3) 197 (94.7) Total N (%) 114 (100.0) 65 (100.0) 29 (100.0) 208 (100.0) ( = ; df=4; p=0.01)
As well as this, the MSPSS evaluates the perceived social support in the three dimensions of a family, friends, and specific individuals which mean except a family and friends. Among three aspects, social support from specific others subscale is significant differences associated with marital status and the number of children.
First of all, the perceived social support from specific evaluated individuals shows there is a correlation with marital status ( = ; df=4; p<0.001). Those who indicated living with a husband or a partner had a higher level of social support from others compared to women who have divorced or separated (Table 3.2.3). While two third of the divorced or separated women were scored as receiving a high level of social support, but about 97 % of women who are living with a husband belonged to the group receiving high social support. As well as this, all of the women living with the partner answered they are receiving a tremendous much of support.
Table 3.2. 3 Distribution by the association between perceived social support and marital status (significant others subscale)
Living with a husband
Living with a partner
Divorced
or separated Total Level of
perceived social support from
Others
Low N (%) 1 (0.7) 0 (0.0) 1 (16.7) 2 (1.0) Moderate N (%) 4 (2.6) 0 (0.0) 1 (16.7) 5 (2.4) High N (%) 146 (96.7) 48 (100) 4(66.7) 198(96.6) Total N (%) 151 (100.0) 48 (100.0) 6 (100.0) 205 (100.0) ( = ; df=4; p<0.001)
Besides, the number of children could affect the perceived social support ( = ; df=4;
p=0.018).
As seen in table 3.2.4, a woman who has two or more children receives less social support than a woman with a child. The majority of women are receiving a high level of social support from specific people. However, women without children have the highest likelihood of receiving perceived social support.
Table 3.2. 4 Relationship between the number of children and social support (significant others subscale)
The number of children None One Two or
more Total
Level of perceived social
support from a specific person
Low N (%) 1 (0.9) 1 (1.5) 1 (3.4) 3 (1.4) Moderate N (%) 0 (0.0) 2 (3.1) 3 (10.3) 5 (2.4)
High N (%) 113 (99.1) 62 (95.4) 25 (86.2) 200 (96.2) Total N (%) 114 (100.0) 65 (100.0) 29 (100.0) 208 (100.0) ( = ; df=4; p=0.018)
Family dimension also has a relationship with how many children women could affect the level of social support ( = ; df=4; p=0.005).
Similar to the results of others dimension, women without children have more social support than women with more than two children from a family (Table 3.2.5). However, friends subscale did not relate to any demographic characteristics.
Table 3.2. 5 Relationship between the number of children and social support (family dimension)
The number of children None One Two or more Total
Level of perceived social
support from family
Low N (%) 0 (0.0) 1 (1.5) 1 (3.4) 2 (1.0) Moderate N (%) 3 (2.6) 2 (3.1) 5 (17.2) 10 (4.8)
High N (%) 111 (97.4) 62 (95.4) 23 (79.3) 196 (94.2) Total N (%) 114 (100.0) 65 (100.0) 29 (100.0) 208 (100.0) ( = ; df=4; p=0.005)
There were two questions about social support related person: 1) Do you have any person who understands and helps you when you need the help? and 2) Who are they you can ask for help? The majority of pregnant women (98.6%) indicated that they have a person who helps them. Only 3 women answered I do not have any person when I need the help. 93.7% of respondents replied that they could get help from their husband or partner. The next highest response was help from the nuclear family (89.3%). 61.5% of participants answered “help from relatives”, 67.8% of participants answered “help from friends”. In addition, eight people responded that they received help from their children and six people who answered that they received help from siblings.
3.3 The emotional wellbeing of pregnant women
3.3.1 Depression
According to Bunevicius (2008), women who have a score of 12 and higher belongs to the depression group. Among 208 women, more than 80% of women are in the low depression group (n=170), and 38 women with a higher risk of depression.
Table 3.3. 1 Distribution of participants by depression level
Depression Number of women %
Low 170 81.7
High 38 18.3
Total 208 100
First of all, it has been found that depression and age of pregnant women are related to each other ( = ; df=2; p=0.034). A woman aged 26 to 34 was found to have a less likelihood of depression, 13.7%. On the other hand, about one-third of women aged over 35 were investigated as being depression, and women under 25 years old showed that approximately 20% of women are with depression.
Table 3.3. 2 Association between depression and age (Chi-square test)
Age 25 26-34 35 Total
Depression N (%) Low 29 (80.6) 113 (86.3) 28 (68.3) 170 (81.7) N (%) High 7 (19.4) 18 (13.7) 13 (31.7) 38 (18.3) Total N (%) 36 (100.0) 131 (100.0) 41 (100.0) 208 (100.0) ( = ; df=2; p=0.034)
Table 3.3.3 shows the results of the chi-square tests by EPDS scores and marital status. Results indicated that there is an association between EPDS scores and marital status ( = ; df=2;
p<0.001). The data indicates that almost 90% of women who live with a partner have a low prevalence of depression. However, divorced or separated women who live without a partner or husband indicated a high prevalence of depression. According to participants, there is no person who lives alone in the low depression group. The woman who is living with a husband has a slightly higher depression frequency (17.2%) than a person who is living with a partner. Thus, the marital status of pregnant women is related to depression.
Table 3.3. 3 Association between Depression and Marital Status of Participants Marital
status Married Living with a partner
Divorced or
Separated Total Depression N (%) Low 125 (82.8) 43 (89.6) 0 (0.00) 168 (82.0)
N (%) High 26 (17.2) 5 (10.4) 6 (100.0) 37 (18.0)
Total N (%) 151 (100.0) 48 (100.0) 6 (100.0) 205 (100.0) ( = ; df=2; p<0.001)
Moreover, the number of children was analysed in terms of depression, and a correlation was found between depression and the number of children (Table 3.3.4). The number of children could affect the degree of depression in pregnant women. A woman with two or more children was found to be more likely to have depression than a woman who does not have children. 34.5% of the women who had two or more children were found to be suffering from depression. Less than 15%
of women without children were suffering from depression.
Table 3.3. 4 Association between depression and the number of children
The number of children None One Two or
more Total
Depression N (%) Low 97 (85.1) 54 (83.1) 19 (65.5) 170 (81.7) N (%) High 17 (14.9) 11 (16.9) 10 (34.5) 38 (18.3) Total N (%) 114 (100.0) 65 (100.0) 29 (100.0) 208 (100.0) ( = ; df=2; p=0.049)
However, there was no association between depression and financial status (p=0.860), the first pregnancy (p=0.631), pregnancy stage (p=0.843), job (p=0.712) and education (p=0.307).
3.3.2 Emotional Status
There is another questionnaire about the feelings and thoughts of pregnant women who answered how they were feeling and thinking in the past 7 days. The overall assessment is done by a total score from 12 to 60. By the level of status, women were divided into 3 groups which composed the dissatisfied group (total score 36), the moderate group (36 total scores 48), and the satisfied group (48 total scores). Over half of the women were satisfied with their emotional status. On the other hand, less than 3% of pregnant women belonged to the dissatisfied group (total score 36), and 44.2% of pregnant women belonged to the moderate group.
Table 3.3. 5 Distribution of participants by the level of emotional status
Number of women %
Level of emotional
status
Dissatisfied 6 2.9
Moderate 92 44.2
Satisfied 110 52.9
Total 208 100.0
First of all, it has been found that the emotional status and marital status of pregnant women are related to each other ( = ;df=4; p<0.001). Table 3.3.6 shows that a person living with a husband or a partner has a high level of satisfaction. However, in the case of divorced or separated pregnant women, their emotional status was negatively impacted meaning that none of the divorced or separated women belonged to the satisfied group. Besides, similar to distribution by the association between depression and marital status (Table 3.3.6), a pregnant woman living with a partner rather than a husband was found to have a more positive emotional condition.
Table 3.3. 6 Association between emotional status and marital status
Marital
status Married Living with a partner
Divorced or
separated Total Emotional
feeling and thought
N (%) Dissatisfied 3 (2.0) 0 (0.0) 2 (33.3) 5 (2.4)
N (%) Moderate 67 (44.4) 21 (43.8) 4 (66.7) 92 (44.9) N (%) Satisfied 81 (53.6) 27 (56.3) 0 (0.00) 108 (52.7) Total N (%) 151 (100.0) 48 (100.0) 6 (100.0) 205 (100.0) ( = ; df=4; p<0.001)
As well as this, this descriptive analysis indicates that there is a correlation between financial status and overall satisfaction of emotional state during pregnancy. About 72.2 % of participants who have a higher standard of living reported that their emotional status was positive during pregnancy, while 48.2% of women who have the average standard of living reported an adverse change in feelings and thoughts.
Table 3.3. 7 Association between emotional statements and financial situation
Financial status Average income
Higher
income Total
Emotional feeling and
thought
N (%) Dissatisfied 5 (2.9) 1 (2.8) 6 (2.9) N (%) Moderate 82 (48.2) 9 (25.0) 91 (44.2)
N (%) Satisfied 83 (48.8) 26 (72.2) 109 (52.9)
Total N (%) 170 (100.0) 36 (100.0) 206 (100.0)
( = ; df=2; p=0.035)
However, there was no association between emotional status and age (p=0.097), first pregnancy (p=0.565), pregnancy stage (p=0.087), number of children (p=0.168), job (p=0.448) and education (p=0.649) in this study.
3.4 Association between social support and emotional wellbeing during pregnancy
Table 3.4.1 below shows a correlation of depression with perceived social support. Women with a high level of social support are less likely to suffer from depression. The women with low- level social support are highly likely to suffer from depression than those who have a high level of support. The analysis revealed that an absence of social support was found to be highly associated with depressiveness in pregnant women.
Table 3.4. 1 Nonparametric correlation between depression and social support, emotional status and social support
Social support Spearman’s rho Depression Correlation coefficient -0.322
p <0.001
Emotional status Correlation coefficient 0.234
p 0.001
In addition, there is a correlation between emotional status with perceived social support.
Women with a high level of social support have a healthy emotional status. The women with low- level social support are more likely to have an unhealthy emotional status than those who have a high level of support. The analysis revealed that the absence of social support was found to be highly associated with the emotional status of pregnant women. Therefore, it is clear that in either case depression or emotional status - social support is a major factor in producing positive emotional and mental health outcomes.
4 DISCUSSION
In this study, almost all women were shown to receive a high level of social support (94.7%).
It is revealed that there is a correlation between social support and the number of children (p=0.01).
Among the women who did not have children (n=114), over 98% were rated as having high social support. However, a woman with two or more children was found to receive less social support when compared to a woman who has only one child. Especially, there is a strong correlation between social support from family or specific persons and the number of children. Similarly, Abdollahpour et al. (73) also found that the mothers perceived social support is significantly related with frequency of pregnancy and with the increasing frequency of pregnancy in mother, the support level becomes lower.
Among the 208 participants, 18.3% of women were shown to have a high level of depression in the study. According to Kuminskas, the prevalence of depressive disorder was about 7%, and the prevalence of depression was about 17% among pregnant women in Lithuania (74). Besides, Josefsson found that depressive symptoms were prevalent in 17% of women during late pregnancy, 17% in the maternal ward, and 13% in six to eight weeks, and six months after delivery (75).
When considering socio-demographic factors and depression, depression was correlated with age, marital status, and the number of children of the mother. First of all, among 3 groups divided by age, 13.7% of women between 26 to 35 years old have a lower risk of depression. However, 19.4% of women under 26 have depression, and 31.7% of women above 34 have depression. The average of EPDS scores of women under 26 years old or above 34 years old, who were considered high risk, had scores that were higher than the average scores of 26-34 years old pregnant women in this study. The mean age of women in the low depression group is 29.78 years old, but the mean age of women in the higher group is 31.61 years old. Similarly, increasing age was also reported as an associative factor for anxiety and depression among pregnant women (76).
It is also found that the depression of the tested women was statistically significantly associated with marital status. The comparison of the prevalence of depression among groups of different marital status (married, cohabiting with a partner, separated, or divorced) revealed that high levels of depression were most prevalent among separated and divorced participants. In particular, all women who were living alone were analysed to have depression in this study, which
was much higher when compared to women living with a partner (17.2%), or married women (10.4%).
Moreover, depression and the variable number of children (p=0.01) was a statistically significant predictor of the EPDS score. The number of children may be regarded as a risk factor for pregnancy-related depression. A woman with two or more children was found to be more likely to have depression than a woman who does not have children. Conversely, 34.5% of the women who had two or more children were found to be suffering from depression. Less than 15% of all women without children were suffering from depression. However, there have been some studies that show there is no significant relationship between the severity of postpartum depression symptoms and the overall number of children in the family (77). It could be assumed that women who have given birth to a consecutive child suffer more physical and psychological pressure, as they need to combine the demands placed on them by a newborn baby with the care of remaining children. Results from the recent population-based study showed that the prevalence of depression and anxiety disorders among pregnant woman is up to 30%, and it seems to be higher during pregnancy than postpartum (78).
The participants lay down into three groups (satisfied, moderate, and unsatisfied), depending on the 12 questions on the feelings and thoughts feel in the last 7 days. From correlation analysis, it has been found that the emotional status and marital status of pregnant women are related to each other. A woman who is living alone was unsatisfied compared to a woman living with a partner or married. One of the interesting results is that living with a husband was expected to be a source of the strong support during pregnancy, however, living with a husband was not an advantage compared to living with a partner. “Living with a partner” was the strongest relationship when considering the association with depression and emotional status. On the other hand, married women, in comparison to cohabiting females, experienced greater satisfaction from being in a relationship and displayed fewer symptoms of postpartum depression. Research performed in Poland showed that married women experienced fewer depression symptoms (77). It might be that because Poland is one of the conservative countries that values religion and traditions, women with a partner are not as satisfied as married women. Also, some women living with a partner might be in a contentious relationship (79). From the results in this study, it is impossible to identify what type of relationship would be positive for emotional wellbeing of pregnant women, however, this would be a valuable consideration in future research.
The emotional status of the respondents and their financial condition were also significantly related. About 72.2% of participants who have a higher standard of living reported that their emotional status was positive during pregnancy. But 48.2% of women who had an average standard of living reported an adverse change in feelings and thoughts. The influence of the financial wellbeing of a woman’s family on her emotional state during pregnancy was found to be positive.
Similarly, a study in Mexico found that a higher household income is correlated with the greater perception of support (80).
There is a correlation between depression and social support, which means women who have a high level of perceived social support have a low probability of antenatal depression. In a study in Canada, it was reported that both the risk of pregnancy depression and postpartum depression considerably increased among those with low social support levels during pregnancy (81). The prospective study of Elsenbruch et al. (82) carried out in Germany measured the social support scores of 896 pregnant women who were in the first trimester of pregnancy. Both the pregnant women and fetus were closely followed until the end of birth. They found that pregnant women with low social support had higher levels of depression symptoms, a decreased quality of life, and smoked more during the pregnancy compared to those with high social support. In the randomized study of Leigh et al. (83) conducted in Australia on 367 pregnant women, it was found that depressive symptom levels were higher among the women who had poor or no social support compared to those with moderate and high levels of social support.
In addition, there is a correlation between emotional status with perceived social support which means women with a high level of social support have a healthy emotional status. Social support offered by a partner or husband that was received before and during pregnancy seems to be critical to the mental wellbeing of pregnant women (84). In the United States, a study with pregnant women found that married women had more support than those unmarried, and partner support coupled with marital stability are essential factors for health and wellbeing(57). In the similar studies, it is emphasized that there is a correlation between social support during pregnancy and depression and anxiety levels and also lack of social support augments levels of depression and anxiety (1, 85).
During early pregnancy, which is a time of significant life-changing psychological adjustments (56), the perception and expectation of insufficient support had a detrimental impact on maternal psychological wellbeing. According to Horowitz and Goodman (2004), overall social support was associated with higher depression among mothers at two years after delivery, which means social support, or lack thereof is influential well beyond the pregnancy period (86, 87). In addition, it is
