Psychological flexibility buffers the impact of negative anticipation and fear of childbirth on prenatal depressive symptoms: insights from the first phase of the flexi-prep cohort study.

Psychological flexibility buffers the impact of negative anticipation and fear of childbirth on prenatal depressive symptoms: insights from the first phase of the flexi-prep cohort study. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 23 June 2025 V1 Latest version Share on Psychological flexibility buffers the impact of negative anticipation and fear of childbirth on prenatal depressive symptoms: insights from the first phase of the flexi-prep cohort study. Authors : Margaux Chopin Chabbert 0000-0002-7266-0978 [email protected] , Sandrine Voillequin 0000-0002-7379-3131 , Noémie Hot , Caroline Diguisto 0000-0002-1176-0991 , and Anne Rousseau 0000-0002-2578-0512 Authors Info & Affiliations https://doi.org/10.22541/au.175064987.73608608/v1 259 views 120 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To determine the psychological factors associated with antenatal depressive symptoms and to assess whether psychological flexibility moderates the relationship between negative anticipation and fear of childbirth and depressive symptoms during pregnancy. Design: Cross-sectional analysis based on baseline data from the Flexi-PREP longitudinal study. Setting and Population: A cohort of 395 pregnant women recruited from three French maternity hospitals during the third trimester of pregnancy. Methods: Participants completed an online survey assessing negative anticipation and fear of childbirth (W-DEQ-A), psychological flexibility (AAQ-II), coping strategies (Brief-COPE), and depressive symptoms (EPDS). Pearson correlations, hierarchical multiple regression, and moderation analyses were conducted. Main Outcome Measures: Symptoms of antenatal depression measured by the Edinburgh Postnatal Depression Scale (EPDS). Results: Higher levels of negative anticipation and fear of childbirth were positively associated with depressive symptoms, while greater psychological flexibility was negatively associated. Avoidant coping strategies were linked to higher depressive symptoms, whereas problem-focused coping showed a marginal protective effect. Hierarchical regression indicated that negative anticipation and fear of childbirth, psychological flexibility, and avoidant coping strategies were significant independent predictors of depressive symptoms. The moderation analysis revealed that psychological flexibility did not significantly moderate the association between fear of childbirth and depressive symptoms (p = .296). However, conditional effects suggested that among women with low psychological flexibility, negative anticipation and fear of childbirth seems to be more strongly associated with depressive symptoms. Conclusions: Psychological flexibility appears to play a protective role in emotional adjustment during pregnancy. Enhancing flexibility through targeted interventions could contribute to reducing antenatal depressive symptoms, particularly among women experiencing high fear of childbirth. Introduction Pregnancy represents a pivotal period for women’s psychological health, often characterised by major biological, psychological, and social changes. While traditionally seen as a time of joyful anticipation, it can also expose women to heightened risks of psychological distress 1 . Among psychiatric complications, antenatal depressive symptoms are increasingly recognised as a major public health issue, affecting approximately 25% of pregnant women globally 1,2 . Antenatal depression is associated with adverse outcomes, including increased risk of preterm birth, low birth weight, and impaired mother-infant bonding 2,3 . One prominent psychological risk factor for antenatal depression is negative anticipation and fear of childbirth, defined as distressing cognitive and emotional evaluations of the upcoming birth 4 . Elevated levels of fear have been consistently linked to greater antenatal depression, anxiety, traumatic birth experiences, and postnatal PTSD 4,5 . Despite its clinical relevance, fear of childbirth has often been studied in isolation without considering its interaction with other psychological vulnerabilities or protective factors. A transdiagnostic perspective has increasingly been adopted to understand emotional disorders across the perinatal period 6 . This framework emphasises that common processes such as emotional inflexibility, experiential avoidance, and maladaptive emotion regulation contribute to a range of disorders. Psychological flexibility, a core process in Acceptance and Commitment Therapy (ACT), has emerged as a key resilience factor 7 . It refers to the ability to stay in contact with the present moment and engage in value-driven behaviours despite unpleasant internal experiences 8 . Higher psychological flexibility enables individuals to adaptively manage stress and reduce emotional distress, whereas low flexibility is associated with depression, anxiety, and stress disorders 9,10 . Critically, psychological flexibility is modifiable. Meta-analyses demonstrate that interventions targeting flexibility can significantly improve mental health outcomes across diverse populations, including perinatal samples 7,11 . However, research specifically focusing on flexibility during pregnancy remains scarce. Coping strategies also play a crucial role. Problem-focused coping (active efforts to resolve stressors) and emotion-focused coping (managing emotional responses) are generally adaptive, whereas avoidant coping (denial, self-distraction) is associated with poorer psychological outcomes during pregnancy 12,13 . Nevertheless, the effectiveness of problem-focused strategies may be limited in contexts characterised by uncontrollable stress, such as childbirth 14 . Another important dimension is childbirth expectations. Women may approach childbirth with either negatively biased or overly idealised expectations. Both extremes can lead to distress if the birth experience deviates from expectations 15,16 . Childbirth, being inherently unpredictable, challenges rigid cognitive frames, highlighting the importance of promoting flexible and realistic expectations during prenatal preparation 17 . Psychological flexibility may not only protect directly against depressive symptoms but also moderate the impact of negative anticipation and fear of childbirth. Previous studies in chronic illness and trauma contexts suggest that flexibility can buffer the emotional consequences of stressors 18,19 , yet this has been rarely explored during pregnancy. In this first phase of the Flexi-PREP study, we aimed to comprehensively investigate the psychological factors associated with antenatal depressive symptoms, with a particular focus on the role of psychological flexibility and coping strategies. Materials and methods Study design The Flexi-PREP study is a longitudinal investigation assessing psychological adaptation from late pregnancy to 3 months postpartum. This article reports exclusively on data collected during the third trimester (Time 1). Data collection occurred between November 2023 and April 2024 across three maternity units in France: Tours, Strasbourg, and Poissy. Ethical approval was obtained from the Research Ethics Committee of Tours-Poitiers (CER-TP 2023-11-03), and all participants provided informed consent. Participants The population in this study comprises a cohort of women who were in their third trimester of pregnancy and agreed to participate in a longitudinal perinatal mental health survey. Inclusion criteria included being aged 18 years or older, a singleton pregnancy with a gestational age of ≥28 weeks, the ability to read and understand French, and willingness to provide informed consent. Exclusion criteria included twin pregnancies or any medical contraindications for participation. Procedure Recruitment was conducted in maternity unit waiting rooms during routine antenatal consultations (e.g., anesthesiology appointments, final prenatal check-ups). Potential participants received verbal and written information about the study and, upon consent, accessed an online questionnaire via QR code or secure web link. Surveys could be completed on-site or later at home. Data collection was managed through LimeSurvey (open-source secure survey platform). Measures Sociodemographic and Obstetric Questionnaire An ad hoc questionnaire, specifically developed for this study, was used to collect sociodemographic data (e.g., age, marital status, employment status, education level), obstetric history (e.g., number of previous pregnancies, complications, breastfeeding history), and current pregnancy details. Additionally, participants were asked about their expectations and concerns regarding the upcoming childbirth (e.g., desire for an epidural, childbirth-related concerns, projections about bonding with the baby). Depressive Symptoms: Edinburgh Postnatal Depression Scale (EPDS) Antenatal depressive symptoms were measured using the 10-item EPDS3, validated for use during pregnancy 20 . Items are scored from 0 to 3 (range 0–30), with higher scores indicating greater symptomatology. A cut-off score ≥13 was used to define clinically significant symptoms. The French version showed good reliability (Cronbach’s α = 0.76) 21 . Psychological Flexibility: Acceptance and Action Questionnaire II (AAQ-II) Psychological flexibility was assessed using the AAQ-II 9 . This 10-item self-report measure evaluates psychological inflexibility (reverse scoring for flexibility). Items are rated from 1 (never true) to 7 (always true), yielding total scores ranging from 10 to 70, with higher scores indicating greater psychological inflexibility. The French validated version demonstrated good reliability (Cronbach’s α = 0.84) 22 . Coping Strategies: Brief COPE Coping was assessed via the Brief COPE Inventory 12 . It includes 28 items grouped into 14 two-item subscales. Respondents indicate how they typically respond to stress using a 4-point Likert scale (1 = “not at all” to 4 = “very much”). Higher scores reflect more frequent use of a given coping strategy. Based on prior research 23,24 , we computed three coping dimensions: Problem-focused coping (active coping, planning, and use of instrumental support); Emotion-focused coping (emotional support, positive reframing, acceptance, humor, and religion); Avoidant coping (self-distraction, denial, substance use, behavioural disengagement, venting, and self-blame). French validated translations were used 25 . Fear of Childbirth: Wijma Delivery Expectancy/Experience Questionnaire-A (W-DEQ-A) Fear and negative anticipation of childbirth were measured using the W-DEQ-A 26 . This is a questionnaire designed to assess expectancy and anticipation of childbirth during the antenatal period, focusing on the feelings and thoughts women may have regarding labor and delivery. For the purpose of this study, a French translation was used based on the most recent version of this tool 27 . The questionnaire originally comprises four independent subscales. Only the ”fearful anticipation” and ”negative expectations” subscales were used for this study (range: 0–110 total). Higher scores reflect greater negative expectations and fear regarding childbirth. Statistics The primary outcome was the level of antenatal depressive symptoms measured by the Edinburgh Postnatal Depression Scale (EPDS). Participants marked ”Excluded – EPDS not completed” (n = 31) were not included in the analysis but completed the follow-up (T2) and will be used in future studies. Those marked ”Excluded – insufficient data” (n = 25) did not complete enough of the baseline questionnaire to be retained. Descriptive analyses were conducted to characterise the sample. Qualitative variables were expressed as numbers and percentages. Continuous variables were expressed as means with standard deviations, maximum and minimum. Before proceeding with the analyses, assumptions for regression and moderation were checked, including multicollinearity, normality of residuals, and linearity of relationships. Pearson’s correlations explored associations between depressive symptoms, negative anticipation and fear of childbirth, psychological flexibility, and coping strategies. Hierarchical multiple regression analyses were conducted to predict depressive symptoms. maternal age, parity and gestational age were entered in Step 1 as control variables. In Step 2, WDEQ-A was added to assess its specific contribution as a potentially novel cognitive-affective predictor. Psychological flexibility (AAQ-II) was introduced in Step 3, reflecting its established role as a transdiagnostic protective resource. Coping strategies were added in Step 4 to explore their additional explanatory value. This stepwise approach allowed for a clearer interpretation of the unique contribution of each set of variables, while controlling for multicollinearity and minimising model overfitting. Finally, moderation analyses tested psychological flexibility as a moderator in the relationship between negative anticipation and depressive symptoms. All predictors and moderators were mean-centered. Data were analysed using JASP version 0.19.3 (Apple Silicon). A significance threshold of p < .05 was applied to all statistical tests. Results Descriptive Analyses A total of 427 pregnant women was initially recruited. After excluding incomplete questionnaires, the final analytic sample consisted of 395 participants (flow chart in figure 1). Participants had a mean age of 31.6 years (SD = 4.7; range 19–47) and completed the questionnaire at a mean gestational age of 35.6 weeks (SD = 2.9; range 25–42). Participants were recruited from three maternity units: Poissy (33.4%), Strasbourg (26.6%), and Tours (40.0%). Most participants were in a relationship (96.7%) and employed (85.3%). Over half were parous (55.4%) and 75.4% had attended antenatal and parenting education (Table 1). Psychological and Emotional Characteristics of the Sample Descriptive statistics were calculated for the main psychological variables. The mean score on the WDEQ-A (negative anticipation and fear of childbirth) was 42.9 (SD = 15.1; range: 5–102). The AAQ-II (psychological flexibility) had a mean of 49.2 (SD = 8.14; range: 25–68). Regarding coping strategies (Brief COPE), the mean scores were 16.01 (SD = 3.3; range: 6–24) for problem-focused coping, 23.32 (SD = 4.17; range: 10–35) for emotion-focused coping, and 22.9 (SD = 3.7; range: 12–48) for avoidant coping. The mean depressive symptom score (EPDS) was 9.4 (SD = 4.9; range: 0–23), with 26.1% of participants scoring above the clinical threshold of ≥13. Correlations Pearson’s correlation coefficients revealed several significant associations between antenatal depressive symptoms (EPDS) and the study variables (Table 2). Higher levels of childbirth-related fear and negative anticipation (W-DEQ-A) were moderately and positively associated with depressive symptoms ( r = .313, p < .001). Psychological flexibility (AAQ-II) showed a strong negative correlation with EPDS scores ( r = –.507, p < .001). Among coping styles (Brief-COPE), avoidant coping showed a moderate positive association with EPDS ( r = .310, p < .001), including self-blame ( r = .408, p < .001), behavioural disengagement ( r = .180, p < .001), denial ( r = .166, p < .001), substance use ( r = .215, p < .001), and self-distraction ( r = .136, p = .007). Conversely, EPDS scores were negatively correlated with acceptance ( r = –.221, p < .001), positive reinterpretation ( r = –.299, p < .001), and humour ( r = –.184, p < .001). Emotion-focused coping showed a significant negative correlation with EPDS ( r = –.194, p < .001), while problem-focused coping was only marginally associated ( r = –.090, p = .073). Multiple Linear Regression Hierarchical linear regression analysis was conducted to predict antenatal depressive symptoms (appendix 1). Sociodemographic variables (maternal age, gestational age, parity) entered in Model 1 did not significantly predict EPDS scores ( p = .069). Adding childbirth fear (WDEQ-A) in Model 2 significantly improved the model (ΔR² = .097, p < .001). Model 3, including psychological flexibility (AAQ-II), further increased explained variance (ΔR² = .167, p < .001). Finally, coping strategies added in Model 4 explained an additional 3.9% of the variance (ΔR² = .039, p < .001), with the final model accounting for 32.1% of the variance ( p < .001). In the final model (Table 3), greater psychological flexibility was strongly associated with lower depressive symptoms (β = -0.355, p < .001), while the use of avoidant coping strategies predicted higher symptoms (β = 0.232, p < .001). Problem-focused coping was associated with a slight decrease in symptoms (β = -0.104, p = .045), while emotion-focused coping was not significant. Maternal age was inversely associated with depressive symptoms (β = -0.091, p = .044). No concerns regarding multicollinearity or residuals distribution were detected. Moderations A moderation analysis (PROCESS model 1) tested whether psychological flexibility (AAQ-II) moderates the effect of fear of childbirth (WDEQ-A) on antenatal depressive symptoms (EPDS). The overall model was significant (R² = .279). Both fear of childbirth (β = .151, p < .001) and psychological flexibility (β = –.451, p < .001) independently predicted depressive symptoms. Although the interaction was not statistically significant (β = –.040, p = .296), conditional effects suggest that negative anticipation and fear of childbirth significantly predicts depressive symptoms among women with low psychological flexibility, but not among those with high flexibility, indicating a potential buffering role of flexibility (Table 4). Discussion Main Findings This study investigated the psychological factors associated with antenatal depressive symptoms among pregnant women. Consistent with previous research, higher levels of negative anticipation and fear of childbirth were moderately associated with greater depressive symptoms 4,5 . Psychological flexibility was strongly negatively associated with depressive symptoms, reinforcing its proposed role as a transdiagnostic resilience factor 7,8,10 . Avoidant coping strategies were also robustly linked to higher depressive symptoms, while problem-focused coping showed only a marginal protective effect 12,13 . Hierarchical regression analyses indicated that negative anticipation and fear of childbirth, psychological flexibility, and avoidant coping independently predicted depressive symptoms, even after controlling for sociodemographic factors. Although the moderation analysis did not reveal a statistically significant interaction between psychological flexibility and fear of childbirth, conditional effects suggested that lower flexibility could exacerbate the emotional impact of childbirth fears. Notably, this study is among the first to simultaneously assess negative anticipation and fear of childbirth, coping strategies, and psychological flexibility within a predictive model of antenatal depressive symptoms. This integrative approach offers a novel contribution to the emerging understanding of perinatal emotional adaptation within a transdiagnostic framework 6,9,19 . Strengths and Limitations This study has several strengths. The large, multicentric sample recruited from three level 3 maternity hospitals enhance generalisability within the French healthcare context. However, because recruitment was limited to highly specialised perinatal centres, the findings may not fully reflect the experiences of women giving birth in lower-level maternity settings. The use of validated psychological instruments for all key constructs strengthens the internal validity of the findings. Moreover, by simultaneously examining multiple psychological constructs, this research addresses a significant gap in perinatal mental health research, which often considers factors in isolation. However, limitations must be acknowledged. The cross-sectional design prevents causal inferences. Although psychological inflexibility and fear of childbirth conceptually precede depressive symptoms, longitudinal designs are needed to empirically establish directionality. The ongoing longitudinal follow-up of the Flexi-PREP study, which includes a second assessment point in the postpartum period, will be crucial in this regard. Self-reported measures may introduce biases, including social desirability and limited introspective accuracy 14,28 . Future research combining self-reports with observational or physiological data could strengthen findings. Furthermore, while our sample was multicentric, it overrepresented women with higher socioeconomic status and strong social support networks, potentially limiting the applicability of findings to more vulnerable populations. Finally, the non-significant moderation effect should be interpreted cautiously. It is possible that psychological flexibility operates through more complex mechanisms, such as mediating emotional regulation abilities or altering appraisal processes, rather than through simple moderation 29,30 . Interpretation in Light of Other Evidence Our results align with previous research showing that fear of childbirth predicts antenatal depression, postpartum PTSD, and negative birth experiences 5,31,32 . The moderate positive correlation between fear of childbirth and depressive symptoms supports previous observations that the anticipation of pain, loss of control, or traumatic outcomes during childbirth can significantly impair maternal mental health 32 . Psychological flexibility’s strong negative association with depressive symptoms is consistent with models highlighting its protective role across diverse populations 7,9,18 . In pregnancy, greater flexibility may allow women to accept uncertainties, adapt to unforeseen complications, and reduce emotional suffering when childbirth experiences deviate from expectations. Interestingly, although psychological flexibility was not a statistically significant moderator in this study, conditional effects suggested trends toward buffering. This raises important questions about how flexibility interacts with other cognitive-affective processes during pregnancy. Future studies could investigate whether flexibility reduces the intensity or frequency of intrusive negative thoughts about childbirth, modulates rumination, or enhances the perceived meaning of the childbirth experience. Regarding coping strategies, avoidant coping emerged as a clear risk factor for depressive symptoms. This finding replicates prior studies demonstrating that disengagement, denial, and behavioural avoidance contribute to the maintenance of emotional distress during pregnancy 13,33 . The limited protective role of problem-focused coping may reflect the intrinsic unpredictability of childbirth, where problem-solving efforts may be futile or even counterproductive when uncontrollable events arise 14,34 . A crucial dimension concerns expectations toward childbirth. Idealised or catastrophising expectations have been shown to increase the risk of emotional distress if unmet 15,16 . Psychological flexibility may function by promoting acceptance of multiple possible outcomes, reducing emotional reactivity to discrepancies between expectations and reality. It would be valuable to further explore how prenatal interventions targeting psychological flexibility can modulate birth-related cognitive expectations. From a broader perspective, our findings support the growing literature advocating for transdiagnostic preventive approaches focused on flexible emotional regulation, rather than targeting specific disorders such as depression or anxiety in isolation 6,9,35 . Given the resource constraints often faced by perinatal services, brief, scalable interventions such as ACT-based prenatal programs could offer significant public health benefits. Conclusion This study highlights the complex interplay between negative anticipation and fear of childbirth, psychological flexibility, coping strategies, and antenatal depressive symptoms. By identifying modifiable psychological processes, this study seeks to inform future preventive interventions to promote maternal mental health during the perinatal period. Psychological flexibility emerged as a strong, independent protective factor against depressive symptoms. Although no statistically significant moderation effect was observed, conditional analyses seem to suggest that higher psychological flexibility might attenuate the emotional impact of childbirth-related fears. Future longitudinal analyses from the Flexi-PREP cohort will be critical in establishing causal pathways and examining how flexible emotional adaptation influences postpartum outcomes, including depression and PTSD. Special attention should be paid to whether flexibility interacts with evolving childbirth expectations over time and whether promoting flexibility prenatally can modify maternal trajectories across the perinatal period. In practice, integrating psychological flexibility training into routine prenatal care—via brief interventions or psychoeducation modules—could provide an accessible, scalable strategy to enhance maternal mental health resilience. Targeting avoidant coping behaviours and promoting acceptance-based regulation may be particularly important among pregnant women at elevated psychological risk. Finally, expanding research to more socioeconomically and culturally diverse populations will be essential to ensure the development of inclusive, effective preventive interventions that address perinatal mental health disparities. Acknowledgements The authors would like to thank all the participants of the Flexi-PREP study for their time and involvement. Disclosure of interests No financial assistance was received for the project. References 1. Míguez MC, Vázquez MB. Prevalence of perinatal depressive symptoms and associated factors: A systematic review. J Affect Disord. 2023;323:372–81. 2. Howard LM, Molyneaux E, Dennis CL, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. Lancet. 2014;384(9956):1775–88. 3. Cox JL, Holden JM, Sagovsky R. 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Keywords epidemiology psychology Authors Affiliations Margaux Chopin Chabbert 0000-0002-7266-0978 [email protected] Universite de Tours View all articles by this author Sandrine Voillequin 0000-0002-7379-3131 CHRU Strasbourg View all articles by this author Noémie Hot CHI Poissy-Saint-Germain-en-Laye Site Hospitalier de Poissy View all articles by this author Caroline Diguisto 0000-0002-1176-0991 Centre Hospitalier Regional Universitaire de Tours Service de Medecine et Biologie de la Reproduction View all articles by this author Anne Rousseau 0000-0002-2578-0512 Paris-Saclay University View all articles by this author Metrics & Citations Metrics Article Usage 259 views 120 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Margaux Chopin Chabbert, Sandrine Voillequin, Noémie Hot, et al. Psychological flexibility buffers the impact of negative anticipation and fear of childbirth on prenatal depressive symptoms: insights from the first phase of the flexi-prep cohort study.. Authorea . 23 June 2025. DOI: https://doi.org/10.22541/au.175064987.73608608/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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