Maternal distress — guilt, depression, and anxiety among mothers of children with and without congenital heart disease

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Methods: This cross-sectional comparative study included 123 mothers of children with CHD and 123 mothers of children without CHD. Participants completed the Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory (BAI), and the Multifactorial Guilt Scale (MGS). Crude and adjusted associations between independent variables and the presence of guilt were estimated using Poisson regression with robust variance to calculate prevalence ratios (PRs). Results: Guilt was highly prevalent, affecting 78% of the total sample. Mothers of children with CHD reported lower levels of guilt but higher levels of anxiety compared with mothers of children without CHD, while depressive symptom levels were similar between groups. Mothers of children without CHD were 35% more likely to experience guilt. The presence of depressive symptoms—mild, moderate, or severe—increased the likelihood of guilt by 21% to 29%. Anxiety was not significantly associated with guilt. Conclusion: Maternal guilt was frequent and strongly associated with depressive symptoms, regardless of the child’s clinical condition. Differences between groups suggest that contextual and caregiving factors may influence emotional experiences. These findings emphasize the need for psychological interventions tailored to the specific profiles and support needs of each group of mothers. Clinical trial number: Not applicable. mother child relationship guilt emotional depression anxiety congenital heart disease Figures Figure 1 HIGHLIGHTS • Maternal guilt was highly prevalent (78%) across the total sample, regardless of the child’s clinical condition. • Mothers of children without congenital heart disease were more likely to experience guilt than mothers of hospitalized children with the condition. • Depressive symptoms significantly increased the likelihood of guilt, whereas anxiety was not significantly associated with this outcome. • Contextual factors, including hospitalization and caregiving demands, appear to differentially shape maternal emotional experiences. • The findings highlight the need for tailored psychological interventions addressing the specific needs of distinct groups of mothers. INTRODUCTION Pregnancy, childbirth, and the postpartum period involve profound physical and psychosocial transitions that evoke a wide range of emotional responses. During pregnancy, mothers construct mental representations of their child’s temperament, appearance, and health, contributing to early bonding (Fuertes et al., 2020 ). Anxiety affects approximately 20%–25% of pregnant women (Domínguez-Solís et al., 2021 ). The transition to parenthood represents a normative developmental crisis within the family system (Bogdan et al., 2022 ), and the quality of early mother–infant interaction plays a critical role in socioemotional development (Darvishvand et al., 2021 ). This period also involves biopsychosocial adjustments, prompting mothers to reflect on their caregiving roles (Gioia et al., 2023 ). When accompanied by a diagnosis of congenital malformation, however, this transition becomes significantly more complex, potentially destabilizing family functioning and parental mental health (Domínguez-Solís et al., 2021 ; Bogdan et al., 2022 ). Among mothers of children with congenital heart disease (CHD), commonly reported emotions include guilt, anger, shock, and fear of the child’s death (Mutti et al., 2024 ; Dandy et al., 2023 ). The demands of intensive caregiving, uncertainty, and anticipatory grief often lead to emotional exhaustion and social isolation (Najafi et al., 2022 ). Parents of children with cyanotic CHD frequently report grief, helplessness, and persistent sadness, regardless of prognosis (Cepuch et al., 2023 ). CHDs remain a leading cause of early childhood morbidity and mortality, affecting 6–12 per 1,000 live births, with approximately half requiring surgery within the first year of life—a period of heightened maternal vulnerability (Pedra et al., 2019 ; Woolf-King et al., 2017 ). Despite advances that reduced CHD-related infant mortality by more than 50% between 1990 and 2021 (Deng et al., 2025 ), caregiving demands remain substantial. Mothers are often primary caregivers during hospitalization, increasing susceptibility to anxiety and depression (Cepuch et al., 2023 ; Pedra et al., 2019 ). Maternal psychological distress may interfere with secure attachment formation and negatively affect child development (Kasparian et al., 2019 ; Rodrigues et al., 2025 ). Evidence underscores the importance of maternal mental health for neurodevelopmental outcomes in children with CHD (Cepuch et al., 2023 ; Woolf-King et al., 2017 ). Family-centered care models and supportive communication from healthcare professionals may mitigate distress and strengthen parental confidence (Gómez-Cantarino et al., 2020 ; Muñoz-Peña et al., 2025 ). Depressive and anxiety symptoms are frequently associated with guilt, a multifaceted construct shaped by moral and social contexts (Aquino and Medeiros, 2009 ). Guilt encompasses subjective, objective, and temporal dimensions and can be assessed using the Multifactorial Guilt Scale (EMC). Although guilt may both contribute to and result from depressive symptoms, its causal direction remains unclear (Luck and Luck-Sikorski, 2020 ). Women report more sources of guilt than men, particularly related to family and interpersonal domains (Luck and Luck-Sikorski, 2022 ). Among parents of infants in intensive care, self-conscious emotions—including guilt, shame, and fear of death—have been shown to explain up to 28% of the variance in psychological distress, with chronic guilt demonstrating a significant association with mothers’ distress (Barr, 2015 ), and maternal depression and anxiety are inversely associated with children’s socioemotional development (Rogers et al., 2020 ). Excessive guilt can undermine psychological well-being and caregiving capacity, precipitating depressive and anxiety symptoms. Despite its clinical and theoretical relevance, research on maternal guilt in the context of congenital heart disease (CHD) remains limited, particularly in low- and middle-income settings where access to psychosocial support may be constrained. Existing evidence suggests that psychological interventions may reduce anxiety, enhance parental confidence, and promote bonding (Ortinau et al., 2022 ). Moreover, most existing studies have focused primarily on anxiety and depression, with comparatively less attention given to guilt as a distinct and potentially modifiable psychological construct. This gap is particularly relevant given the multidimensional nature of guilt and its potential role as both a risk factor and a maintaining mechanism of maternal psychological distress. A deeper understanding of maternal guilt may contribute to improved screening strategies and the development of more targeted psychosocial interventions within pediatric cardiology settings. Clarifying how guilt interacts with depressive and anxiety symptoms may also support more comprehensive models of maternal mental health, integrating emotional, cognitive, and contextual dimensions. Such knowledge is essential to inform clinical practices that are sensitive not only to the child’s medical condition but also to the psychological needs of caregivers. Therefore, the present study aims to: (1) examine the prevalence and dimensions of guilt among mothers of children with CHD compared to mothers of children without CHD; (2) investigate the association between guilt and symptoms of depression and anxiety; and (3) identify sociodemographic and clinical factors associated with maternal guilt. We hypothesize that mothers of children with CHD will present higher levels of guilt and psychological distress, and that guilt will be significantly associated with depressive and anxiety symptoms. By addressing these objectives, this study seeks to advance the understanding of maternal psychological distress in the context of chronic pediatric illness and to support the development of targeted, evidence-based interventions aimed at improving maternal well-being and strengthening family-centered care. Excessive guilt can undermine psychological well-being and caregiving capacity, precipitating depressive and anxiety symptoms. Despite its relevance, research on maternal guilt in the context of CHD remains limited. Existing evidence suggests that psychological interventions may reduce anxiety, enhance parental confidence, and promote bonding (Ortinau et al., 2022 ). Therefore, this study aims to examine the prevalence of guilt among mothers of children with congenital heart disease, explore its association with depressive and anxiety symptoms, and identify related factors, contributing to the development of targeted interventions to strengthen maternal mental health and family care quality. MATERIALS AND METHODS This cross-sectional, descriptive, and comparative study employed a non-probabilistic sampling method. The sample comprised mothers aged ≥ 18 years with children up to 9 years old (WHO, 2024) hospitalized in a reference cardiology hospital, where interviews were conducted during hospitalization. A comparison group consisted of mothers of children without congenital heart disease or other chronic diseases, recruited through preschools. Invitations, informed consent forms, and interview availability requests were distributed via these institutions, and consenting mothers were subsequently interviewed. This study complied with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the Institute of Cardiology (Brazil) under protocol number CAAE: 73187923.6.0000.5333. All participants provided written informed consent prior to study inclusion and subsequently completed the following standardized questionnaires: Multifactorial Guilt Scale (MFGS) – Escala Multifatorial de Culpa (EMC) - Developed and validated for the Brazilian population by Aquino and Medeiros ( 2009 ), the EMC is a 12-item instrument structured into three dimensions. Objective Guilt refers to concrete actions or omissions involving actual transgressions or violations of norms, which render the individual objectively guilty, regardless of subjective emotional experience (e.g., “I regret something I should not have done”). Subjective Guilt reflects an internal emotional state characterized by remorse, shame, guilt, and self-condemnation in response to thoughts, impulses, or behaviors perceived as inappropriate or morally wrong (e.g., “I feel guilty for having bad thoughts”). Temporal Guilt is associated with the human experience of time constraints and role overload, reflecting guilt related to insufficient time devoted to family or significant others (e.g., “I usually feel guilty for not having time for the people I love”) Beck Depression Inventory–II (BDI-II) - The Beck Depression Inventory–II (BDI-II) is a self-report instrument validated for the Brazilian population, consisting of 21 items that assess depressive symptoms experienced over the previous week. Total scores range from 0 to 63 and are classified as follows: 0–13 (minimal or no depression), 14–19 (mild depression), 20–28 (moderate depression), and 29–63 (severe depression) Gomes-Oliveira et al. 2012 ). Beck Anxiety Inventory (BAI) - The Beck Anxiety Inventory (BAI), translated and validated in Brazil, consists of 21 items that reflect the physical, emotional, and cognitive symptoms of anxiety. Each item includes four response options indicating increasing levels of symptom severity, ranging from 0 to 3. The total score ranges from 0 to 63, allowing classification of anxiety levels as follows: 0–10 (minimal anxiety), 11–19 (mild anxiety), 20–30 (moderate anxiety), and 31–63 (severe anxiety) (Cunha 2001 ). The required sample size was estimated to detect a difference in the prevalence of depression between mothers with and without guilt. A total of 123 participants were required, allocated in a 1:2 ratio (41 in the guilt group and 82 in the no-guilt group). The calculation assumed a statistical power of 80%, a two-sided significance level of 5%, and expected prevalence rates of 25% and 5%, respectively, based on Luck and Luck-Sikorski ( 2020 ). The estimation was performed using the online sample size calculator provided by PSS Health (Borges et al. 2021 ). Categorical variables were described as absolute and relative frequencies, and continuous variables as means and standard deviations. Group comparisons were performed using the chi-square test or Fisher’s exact test, as appropriate, for categorical variables, and the independent samples Student’s t -test for continuous variables, after assessment of distributional assumptions. To examine guilt levels, total scores from the Multifactorial Guilt Scale (EMC) were categorized according to the sample median. Scores were dichotomized into no guilt (0–26 points) and presence of guilt (≥ 27 points), and further classified into mild (27–33 points), moderate (34–38 points), and severe guilt (39–60 points). Crude and adjusted associations between independent variables and the presence of guilt were estimated using Poisson regression with robust variance to obtain prevalence ratios (PR) and corresponding 95% confidence intervals (95% CI). Variables with p < 0.20 in the bivariate analyses were considered eligible for inclusion in the multivariable model. Statistical significance was defined as p < 0.05. All analyses were performed using IBM SPSS Statistics. RESULTS Between September 2023 and February 2025, 242 children with congenital heart disease were admitted to the pediatric ward or intensive care unit, of whom 135 were accompanied by their mothers, and 123 were included in the case group. For the comparison group, 179 mothers were contacted through school referrals; 135 responded, resulting in a final sample of 123 mothers, as shown in Fig. 1 . The mothers of children with congenital heart disease were predominantly White (79.7%), had a partner (39% married and 17.1% in a stable union), and had completed secondary or technical education (42.3%). Most participants were engaged in paid employment (56.9%), belonged to low-income socioeconomic groups (64.2%), and approximately one-third resided in the metropolitan region of Porto Alegre/Brazil (29.5%). Half of the mothers (50.4%) had previously undergone psychological counseling, and 22% had received psychiatric care at some point in their lives. Additionally, 25.2% were using psychotropic medication. The children had a mean age of 4.8 years, and regarding their medical conditions, 78.9% had acyanotic congenital heart disease (Table 1 ). Mothers in the group without congenital heart disease were predominantly White (91.1%), had a partner (52.8% married and 24.4% in a stable union), 18.5% had completed upper secondary and the remaining participants had completed tertiary education. Most participants were engaged in paid employment (85.4%), and a smaller proportion than in the other group belonged to low-income socioeconomic groups (29.3%). Additionally, 65.3% resided in the metropolitan region of Porto Alegre, Brazil. Half of the mothers (50.4%) had previously undergone psychological counseling, and 24.4% had received psychiatric care at some point in their lives. Additionally, 24.4% were using psychotropic medication. The children had a mean age of 6.2 years and had no congenital heart disease or other chronic condition (Table 1 ). Table 1 – Sociodemographic and psychological characteristics of mothers of children with and without congenital heart disease Maternal Characteristics children with CHD n = 123 children without CHD n = 123 P* Sociodemographic characteristics Age, years 34.25 ± 7.30 36.96 ± 5.55 0.001 White, n (%) 98 (79.7) 112 (91.1) 0.041 Had a partner, n (%) 69 (56.1) 95 (77.2) < 0.001 Year of study, n (%) 12.36 ± 4.55 18.23 ± 8.43 < 0.001 Employment, n (%) 70 (56.9) 105 (85.4) < 0.001 Low-income, n (%) 79 (64.2) 36 (29.3) < 0.001 Metropolitan region, n (%) 36 (29.5) 79 (65.3) < 0.001 Undergone psychological counseling, n (%) 62 (50.4) 62 (50.4) 1.000 Undergone psychiatric care, n (%) 27 (22.0) 30 (24.4) 0.763 Using psychotropic medication, n (%) 31 (25.2) 30 (24.4) 0.883 Number of children, count 2.07 ± 1.23 1.63 ± 0.76 0.001 Children Child’s age, years 4.85 ± 3.95 6.18 ± 3.45 0.005 Heart disease classification Acyanotic congenital heart disease n (%) 97 (78,9) - Psychological Characteristics Guilt EMC Score 30.96 ± 9.24 35.90 ± 7.98 < 0.001 Subjective guilt 9.44 ± 3.21 10.85 ± 3.43 0.001 Objective guilt 9.12 ± 3.86 11.28 ± 3.08 < 0.001 Temporal guilt 12.31 ± 04.23 13.78 ± 3.44 0.003 Absent, n (%) 42 (34.1) 12 (7.5) Mild, n (%) 30 (24.4) 33 (26.8) < 0.001 Moderate, n (%) 30 (24.4) 39 (31.7) Severe, n (%) 21 (17.1) 39 (31.7) Depression BDI Score 13.10 ± 8.84 11.52 ± 8.98 0.166 Absent, n (%) 45 (36.6) 61 (50.4) Mild, n (%) 49 (39.8) 41 (33.9) 0.133 Moderate, n (%) 23 (18.7) 14 (11.6) Severe, n (%) 6 (4.9) 6 (4.9) Anxiety BAI Score 18.50 ± 10.80 12.18 ± 10.16 < 0.001 Absent, n (%) 32 (26.0) 68 (56.2) Mild, n (%) 37 (30.1) 26 (21.5) < 0.001 Moderate, n (%) 36 (29.3) 20 (16.5) Severe, n (%) 18 (14.6) 7 (5.8) EMC - Multifactorial Guilt Scale; BDI- Beck Depression inventory; BAI – Beck anxiety Inventory. According to Table 1 , we observed significant differences in sociodemographic characteristics such as age, race, years of education, number of children, and whether the mothers lived with a partner. We also found that mothers of children with congenital heart disease were less likely to be engaged in paid employment, more frequently lived outside the metropolitan region, and more commonly belonged to low-income socioeconomic groups. The age of the children also differed significantly, with those with heart disease being younger. Regarding psychological characteristics, mothers of children with congenital heart disease exhibited lower levels of guilt across all dimensions and higher anxiety compared with the others. Depression levels were similar in both groups. Given the sociodemographic differences identified in the sample, we proceeded to analyze guilt and associated factors. Based on the median guilt score, we examined two groups of mothers: those with guilt (> 26 points) and those without guilt (≤ 26 points). Table 2 Sociodemographic and psychological characteristics based on mothers’ guilt levels Characteristics With guilt n = 192 (78%) Without Guilt n = 54 (22%) p* Sociodemographic characteristics Age, years 35.6 ± 6.6 35.5 ± 6.5 0.894 White, n (%) 166 (86.5) 44 (81.5) 0.516 Has a partner, n (%) 130 (67.7) 34 (63) 0.517 Year of study, years 15.8 ± 7.6 13.2 ± 5.7 0.018 Employment, n (%) 141 (73.4) 34 (63) 0.321 Socioeconomic classes D e E, n (%) 85 (44.3) 30 (55.6) 0.166 Metropolitan region, n (%) 94 (49.7) 21 (38.9) 0.496 Undergone psychological counseling, n (%) 101 (52.6) 23 (42.6) 0.219 Undergone psychiatric care, n (%) 50 (26) 7 (13) 0.046 Using psychotropic medication, n (%) 54 (28.1) 7 (13) 0.021 Number of children, count 1.79 ± 0.9 2.06 ± 1.2 0.141 Children Child’s age, years 5.5 ± 3.7 5.3 ± 3.9 0.663 Children with congenital heart disease, n (%) 81 (42.2) 42 (77.8) < 0.001 Psychological Characteristics Depression BDI Score 13.81 ± 9.08 6.98 ± 5.82 < 0.001 Ansent, n (%) 70 (36.5) 37 (68.5) Mild, n (%) 76 (39.6) 14 (25.9) 0.001 Moderate, n (%) 34 (17.7) 3 (5.6) Severe, n (%) 12 (6.3) 0 (0) Anxiety BAI Score 16.38 ± 11.14 11.67 ± 9.36 0.005 Absent, n (%) 73 (38) 28 (51.9) Mild, n (%) 47 (24.5) 16 (29.6) 0.009 Moderate, n (%) 48 (25) 8 (14.8) Severe, n (%) 24 (12.5) 2 (3.7) EMC - Multifactorial Guilt Scale; BDI- Beck Depression inventory; BAI – Beck anxiety Inventory. According to Table 2 , the factors associated with guilt were years of education—with higher educational attainment in the group with guilt—prior psychiatric follow-up, and psychotropic medication use, both of which were more frequent in this group. Similarly, mean depression and anxiety scores were higher in the guilt group. Both the total scores and the categorical classifications of the BDI and BAI were statistically significant. It was also observed that, in the guilt group, there were fewer mothers of children with congenital heart disease (42.2% vs. 77.8%, p < 0.001). In Table 3 , we present the factors associated with guilt. In addition to the variables that were statistically significant between mothers with and without guilt, we included in the model all sociodemographic variables that differed between mothers of children with and without congenital heart disease. Among all variables, the mothers’ group and depression were the factors associated with guilt. Table 3 Multivariate analysis of factors associated with guilt Factors associated with guilt B (EXP) 95% confidence interval p* Mothers in the non-CHD group 1.282 1.145–1.436 < 0.001 White 0.930 0.776–1.114 0.430 Socioeconomic Class D and E 1.019 0.913–1.138 0.738 Lives in a metropolitan region 0.900 0.980–1.079 0.676 Employment 0.972 0.967–1.090 0.627 Has a partner 0.969 0.863–1082 0.578 Undergone psychiatric care 0.987 0.889–1.097 0.813 Undergone psychological counseling 0.953 0.857–1060 0.371 BAI Score 0.996 0.990–1.001 0.110 BDI Score 0.986 0.980–0.993 < 0.001 Yaers of study 1.000 0.994–1.005 0.890 Child’s age 1.004 0.990–1.018 0.593 Mother’s age 0.998 0.990 = 1.006 0.687 Number of children 1.030 0.980–1083 0.245 When analyzing only the group of mothers and the severity of anxiety and depression, we observed that mothers of children without congenital heart disease had a 35% higher likelihood of experiencing guilt compared with those whose children had heart disease. Having mild, moderate, or severe depression increased the likelihood of guilt by 21% to 29%. Anxiety, however, was not associated with guilt (Table 4 ). Table 4 Association between mothers’ group, levels of depression and anxiety, and guilt Factors associated with guilt B (EXP) Intervalo de 95% de confiança P* Mothers in the non-CHD group 1.345 1.218–1.286 < 0.001 Depression Mild 1.210 1.082–1.353 0.001 Moderate 1.291 1.123–1.484 < 0.001 Severe 1.287 1.101–1.506 0.002 Anxiety Mild 1.037 0.914–1.176 0.575 Moderate 1.130 0.993–1.290 0.063 Severe 1.160 0.982–1.384 0.079 DISCUSSION AND CONCLUSIONS The present findings indicate that guilt was highly prevalent, affecting 78% of the sample. Although present in both groups, it was significantly less frequent among mothers of children with congenital heart disease (CHD) than among mothers of children without chronic conditions. Depressive symptoms were strongly associated with guilt, increasing its likelihood by more than 20%, reinforcing the established link between self-blame and depression. At first glance, lower guilt levels among mothers of children with CHD may seem unexpected given the clinical severity and emotional burden of chronic illness. However, this result can be understood within the hospitalization context. Most children with CHD were admitted to pediatric units requiring continuous caregiver presence, a role predominantly assumed by mothers. Sustained involvement in daily care and decision-making may enhance maternal perceptions of competence and efficacy, thereby mitigating guilt. Continuous engagement may also strengthen the mother–child bond, consistent with family-centered care principles (Gómez-Cantarino et al., 2020 ). In addition, professional guidance within the hospital setting may serve as a temporary support network, buffering excessive self-blame. Conversely, mothers of children without CHD may be more exposed to socially constructed and often unattainable ideals of motherhood, intensifying self-critical cognitions and guilt (Hubert and Aujoulat, 2018 ). These findings underscore the role of contextual and sociocultural factors in shaping maternal emotional experiences. Perceived maternal efficacy—how mothers interpret the impact of their caregiving—was closely related to guilt and parental competence. When distorted, such perceptions increase the risk of parental stress (Muñoz-Peña et al., 2025 ). In this study, higher guilt levels were associated with greater depressive symptomatology, particularly among mothers of children without CHD, suggesting a possible pattern of maternal burnout even in the context of healthy children. As noted by Hubert and Aujoulat ( 2018 ), mothers of healthy children often overinvest in the maternal role, attempting to simultaneously manage multiple responsibilities, which may foster persistent inadequacy and psychological distress. The clinical relevance of these findings is reinforced by the fact that, among mothers reporting guilt, 50% had received psychological care, 26% psychiatric follow-up, and 28% had used psychotropic medication. These results also raise concerns that mothers of children with CHD may experience increased guilt and depressive symptoms after hospital discharge, when the demands of complex home-based care are added to routine parenting responsibilities, potentially exacerbating emotional overload if perceptions of competence decline. Another relevant finding was the high proportion of paid employment among mothers of children without congenital heart disease (85.4%), which may partially explain their higher levels of guilt. Tohme and Abi-Habib ( 2022 ) note that guilt in working mothers is often linked to role overload, encompassing professional demands in addition to childcare and household responsibilities. In contrast, only 56.9% of mothers of children with congenital heart disease were employed, consistent with prior literature indicating that these mothers frequently assume primary caregiving and follow-up responsibilities, often withdrawing from the workforce (Najafi et al., 2022 ). However, leaving paid work may also increase vulnerability to depressive symptoms, as only 36.6% of mothers of children with congenital heart disease were free of depressive symptomatology. Regardless of employment status, mothers typically remain primarily responsible for domestic tasks and childcare. Those engaged in paid work—particularly without adequate support—may perceive greater difficulty in balancing competing demands, and unmet expectations in these domains have been associated with heightened guilt and stress (Coogan and Chen, 2007 ). The present study showed that depressive symptoms—mild, moderate, or severe—increased the likelihood of experiencing guilt by 21% to 29%. This association may be understood in light of Beck’s cognitive triad, characterized by negative views of the self, the world, and the future, which can undermine perceived self-efficacy and intensify guilt (Muñoz-Peña et al., 2025 ). Evidence also suggests that women report more sources of guilt than men. In a 2022 study, 255 male participants reported 573 reasons for guilt, whereas 346 female participants reported 926 reasons, most related to their children (Luck and Luck-Sikorski, 2022 ). Maternal guilt is thus embedded in a social discourse that promotes the idealized and often unattainable image of the “perfect mother.” The gap between social expectations and lived experience may foster feelings of failure, exhaustion, and depressive symptoms (Hubert and Aujoulat, 2018 ; Law et al., 2021 ). Among mothers of children with congenital heart disease, depressive and anxiety symptoms are generally more prevalent (Mutti et al., 2024 ). In that study, 74% of these mothers reported anxiety symptoms (30.1% mild, 29.3% moderate, 14.6% severe), compared with 43.8% among mothers of children without the condition. This pattern is consistent with prior research linking the diagnosis of a severe pediatric illness to elevated anxiety (Oftedal et al., 2022 ; Woolf-King et al., 2017 ; Dandy et al., 2023 ). Hospitalization—requiring assimilation of complex medical information, anticipation of procedures, and coping with postoperative recovery—may further intensify distress (Woolf-King et al., 2017 ). However, no association was found between guilt and anxiety in the present study, in line with Fergus et al. ( 2010 ), who reported a stronger relationship between shame and anxiety than between guilt and anxiety. Contrary to our initial hypothesis that mothers of children with CHD would present higher levels of guilt and psychological distress, the present findings revealed a more nuanced pattern. While psychological distress—particularly depressive symptoms—was indeed strongly associated with guilt, mothers of children with CHD did not exhibit higher levels of guilt compared to mothers of children without chronic conditions. This partially refutes our hypothesis and suggests that guilt may not be solely determined by the severity of the child’s clinical condition, but rather by contextual, cognitive, and sociocultural factors. The hypothesis regarding the association between guilt and depressive and anxiety symptoms was only partially supported: a robust relationship was observed between guilt and depression, whereas no significant association was found with anxiety. These results reinforce the conceptualization of guilt as more closely aligned with depressive cognitive patterns, such as self-blame and negative self-evaluation, than with anxiety-related processes. Furthermore, the lower levels of guilt observed among mothers of children with CHD may reflect the buffering effects of structured care environments, increased maternal involvement, and professional support, which can enhance perceived maternal efficacy. In contrast, mothers of children without chronic conditions may be more vulnerable to internalized social expectations and idealized standards of motherhood, contributing to heightened guilt despite the absence of a medical condition. Together, these findings highlight the importance of moving beyond disease-centered assumptions and considering the broader psychosocial context when examining maternal emotional experiences. One limitation of this study concerns the subjective nature of psychological constructs and the reliance on self-report instruments, which may not fully capture the complexity of emotional experiences. Sociodemographic differences between groups, although statistically adjusted, may also have influenced the results. Additionally, voluntary participation among school-recruited mothers may have introduced selection bias, as the topic of guilt could have attracted those more affected by this feeling. The inclusion of a comparison group strengthened contextual interpretation; however, the fact that many hospitalized children were not accompanied by their mothers during the interview period may have introduced further bias, since the reasons for maternal absence during an average week of hospitalization remain unknown. In this cross-sectional comparative study based on real-world data, maternal guilt was highly prevalent, affecting 78% of the sample. Mothers of children without congenital heart disease were more likely to report guilt, and depressive symptoms significantly increased its likelihood. Although anxiety was more frequent among mothers of hospitalized children, it was not associated with guilt. These findings underscore the importance of tailored psychological interventions that address the specific contextual and emotional needs of each group and may also be applicable to mothers of children with other chronic conditions. Declarations Acknowledgments To all the mothers who were willing to share their feelings with us, our gratitude. To CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), a foundation linked to the Brazilian Ministry of Education (MEC), which provided the master's and doctoral scholarships; and to CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), which provided the undergraduate research scholarship. Author Contributions R.C.P. Conception and design of the study; methodological development; data collection; statistical analysis; data interpretation; manuscript drafting; responsibility for the integrity of the data; final approval of the version to be published. D.R.V. Data collection; data interpretation; critical revision of the manuscript for important intellectual content; responsibility for the integrity of the data; final approval of the version to be published. A.P.M. Data collection; responsibility for the integrity and accuracy of the data; final approval of the version to be published. M.M.S. Conception and design of the study; data interpretation; statistical analysis; critical revision of the manuscript for important intellectual content; final approval of the version to be published. Conflict of Interest Statement The authors declare that they have no conflicts of interest to disclose. Funding Statement Not applicable . Ethical Approval and Informed Consent Statements The study was approved by the institutional ethics committee under CAAE number 73187923.6.0000.5333 and was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants provided written informed consent. Data Availability Statement The data supporting the findings of this study were collected using the REDCap® platform and are available in anonymized form at the Open Science Framework (OSF) repository (https://osf.io/gm5cn/). The dataset includes responses to the EMC (Multifactorial Guilt Scale), BDI-II, and BAI questionnaires. Access is unrestricted for research purposes. Consent for publication Not applicable. References de Aquino TAA, Medeiros B. Escala de culpabilidade: Construção e validação de construto. Aval psicol. 2009;8:77–86. Barr P. Guilt, shame and fear of death predict neonatal intensive care unit-related parental distress. J Reprod Infant Psychol. 2015;33:402–13. Bogdan I, Turliuc MN, Candel OS. Transition to parenthood and marital satisfaction: A meta-analysis. Front Psychol. 2022. https://doi.org/10.3389/fpsyg.2022.901362 . Borges RB, Mancuso ACB, Camey SA, Leotti VB, Hirakata VN, Azambuja GS, et al. Power and Sample Size for Health Researchers: Uma ferramenta para cálculo de tamanho amostral e poder do teste voltado a pesquisadores da área da saúde. Clin biomed res. 2021. https://doi.org/10.22491/2357-9730.109542 . Cepuch G, Kruszecka-Krówka A, Lalik A, Micek A. Parents’ toxic stress as a potential factor inducing negative emotions of newborns and infants with cyanotic congenital heart disease. Children. 2023. https://doi.org/10.3390/children10121893 . Coogan PA, Chen CP. Career development and counselling for women: Connecting theories to practice. Couns Psychol Q. 2007;20:191–204. https://doi.org/10.1080/09515070701391171 . Cunha JA. (2001) Manual da versão em português das Escalas Beck. [Manual of the Portuguese Adaptation of the Beck Scales] Casa do Psicólogo, São Paulo. Dandy S, Wittkowski A, Murray CD. Parents’ experiences of receiving their child’s diagnosis of congenital heart disease: A systematic review and meta-synthesis of the qualitative literature. Br J Health Psychol. 2023;29:351–78. https://doi.org/10.1111/bjhp.12703 . Darvishvand M, Khalesi ZB, Rahebi SM. Mother–infant relationship and its predictors. JBRA Assist Reprod. 2021;26:68–72. https://doi.org/10.5935/1518-0557.20210029 . Deng L, Li Q, Cheng Z. Evaluating the global, regional, and national burden of congenital heart disease in infants younger than 1 year: A 1990–2021 systematic analysis for the GBD study 2021. Front Pediatr. 2025. https://doi.org/10.3389/fped.2025.1467914 . Domínguez-Solís E, Lima-Serrano M, Lima-Rodríguez JS. Non-pharmacological interventions to reduce anxiety in pregnancy, labour and postpartum: A systematic review. Midwifery. 2021. https://doi.org/10.1016/j.midw.2021.103126 . Fergus TA, Valentiner DP, McGrath PB, Jencius S. Shame- and guilt-proneness: Relationships with anxiety disorder symptoms in a clinical sample. J Anxiety Disord. 2010;24:811–5. http://www.doi.org/10.1016/j.janxdis.2010.06.002 . Fuertes M, Ribeiro C, Gonçalves JL, Rodrigues C, Beeghly M, Lopes-dos-Santos P, et al. Maternal perinatal representations and their associations with mother–infant interaction and attachment: A longitudinal comparison of Portuguese and Brazilian dyads. Int J Psychol. 2020;55(2):224–33. Gioia MC, Cerasa A, Muggeo VMR, Tonin P, Cajiao J, Aloi A et al. (2023) The relationship between maternal–fetus attachment and perceived parental bonds in pregnant women. Front Psychol, 13. Gómez-Cantarino S, García-Valdivieso I, Moncunill-Martínez E, Yáñez-Araque B, Ugarte Gurrutxaga MI. Developing a family-centered care model in the neonatal intensive care unit (NICU): A new vision to manage healthcare. Int J Environ Res Public Health. 2020;17(19). http://www.doi.org/10.3390/ijerph17197197 . Gomes-Oliveira MH, Gorenstein C, Neto FL, Andrade LH, Wang YP. Validation of the Brazilian Portuguese version of the Beck Depression Inventory-II in a community sample. Rev Bras Psiquiatr. 2012;34(4):389–94. http://www.doi.org/10.1016/j.rbp.2012.03.005 . Hubert S, Aujoulat I. Parental burnout: When exhausted mothers open up. Front Psychol. 2018;9. http://www.doi.org/10.3389/fpsyg.2018.01021 . Kasparian NA, Kan JM, Sood E, Wray J, Pincus HA, Newburger JW. Mental health care for parents of babies with congenital heart disease during intensive care unit admission: Systematic review and statement of best practice. Early Hum Dev. 2019;139:104837. http://www.doi.org/10.1016/j.earlhumdev.2019.104837 . Law S, Ormel I, Babinski S, Plett D, Dionne E, Schwartz H, et al. Dread and solace: Talking about perinatal mental health. Int J Ment Health Nurs. 2021;30:S1. Luck T, Luck-Sikorski C. Feelings of guilt in the general adult population: Prevalence, intensity and association with depression. Psychol Health Med. 2020;26(9):1143–53. Luck T, Luck-Sikorski C. (2022) The wide variety of reasons for feeling guilty in adults: Findings from a large cross-sectional web-based survey. BMC Psychol, 10(1). Muñoz-Peña IJ, González-Gutiérrez JL, Yunta-Rua L, Pacho-Hernández JC, López-López A. Stress, perceived competence and guilt as predictors of depression in parents with chronic pain. Front Psychol. 2025;15. http://www.doi.org/10.3389/fpsyg.2024.1473955 . Mutti G, Ait Ali L, Marotta M, Nunno S, Consigli V, Baratta S, et al. Psychological impact of a prenatal diagnosis of congenital heart disease on parents: Is it time for tailored psychological support? J Cardiovasc Dev Dis. 2024;11(1):31. http://www.doi.org/10.3390/jcdd11010031 . Najafi K, Shirinabadi Farahani A, Rassouli M, Alavi Majd H, Karami M. Emotional upheaval as the essence of anticipatory grief in mothers of children with life-threatening illnesses: A qualitative study. BMC Psychol. 2022;10(1). http://www.doi.org/10.1186/s40359-022-00904-7 . Oftedal A, Bekkhus M, Haugen G, Hjemdal O, Czajkowski NO, Kaasen A. Long-term impact of diagnosed fetal anomaly on parental traumatic stress, resilience, and relationship satisfaction. J Pediatr Psychol. 2022;48(2). http://www.doi.org/10.1093/jpepsy/jsac085 . Ortinau CM, Smyser CD, Arthur L, Gordon EE, Heydarian HC, Wolovits J, Nedrelow J, Marino BS, Levy VY. Optimizing neurodevelopmental outcomes in neonates with congenital heart disease. Pediatrics. 2022;150(Suppl 2):e2022056415L. http://www.doi.org/10.1542/peds.2022-056415L . Pedra SRFF, Zielinsky P, Binotto CN, Martins CN, Fonseca ESVB, Guimarães ICB, et al. Brazilian fetal cardiology guidelines—2019. Arq Bras Cardiol. 2019;112(5):600–48. http://www.doi.org/10.5935/abc.20190075 . Rogers A, Obst S, Teague SJ, et al. Association between maternal perinatal depression and anxiety and child and adolescent development: A meta-analysis. JAMA Pediatr. 2020;174(11):1082–92. http://www.doi.org/10.1001/jamapediatrics.2020.2910 . Rodrigues BMS, Melo EP, Nascimento IR. Fortalecendo laços em tempos difíceis. Rev SBPH. 2025;28:e009. org/10.57167/rev-sbph.2025.v28.710 . http://www.doi. . Tohme P, Abi-Habib R. Correlates of work productivity and maternal competence after having a baby: The roles of mother–infant bonding and maternal subjective experiences. BMC Womens Health. 2022;22(1). http://www.doi.org/10.1186/s12905-022-01958-w . Woolf-King SE, Anger A, Arnold EA, Weiss SJ, Teitel D. Mental health among parents of children with critical congenital heart defects: A systematic review. J Am Heart Assoc. 2017;6(2). http://www.doi.org/10.1161/JAHA.116.004862 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 22 Apr, 2026 Editor assigned by journal 22 Apr, 2026 Editor invited by journal 14 Apr, 2026 Submission checks completed at journal 14 Apr, 2026 First submitted to journal 14 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9383132","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633492055,"identity":"86c6caa1-3777-4a0e-bca1-ab6d2b327790","order_by":0,"name":"Rafaela Campos Peruchi","email":"","orcid":"","institution":"Fundação Universitária de Cardiologia","correspondingAuthor":false,"prefix":"","firstName":"Rafaela","middleName":"Campos","lastName":"Peruchi","suffix":""},{"id":633492056,"identity":"89ff763b-415c-433c-9e64-62af9c95ab21","order_by":1,"name":"Daniela da Rosa Vieira","email":"","orcid":"","institution":"Fundação Universitária de Cardiologia","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"da Rosa","lastName":"Vieira","suffix":""},{"id":633492057,"identity":"26e32d4b-887a-4a3a-b159-118f14167b12","order_by":2,"name":"Alice Peixoto Martins","email":"","orcid":"","institution":"Fundação Universitária de Cardiologia","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"Peixoto","lastName":"Martins","suffix":""},{"id":633492059,"identity":"8e3f1f91-5703-4252-9cbc-7c9bacbdf6ec","order_by":3,"name":"Marcia Moura Schmidt","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYFADZgaGwz8MbIAsxsYDxGphfMxQkQbS0kCkFqAmY4Yzh8EsvFp023vMPvzMscvnb2d+Jl3Ydt5ubfthoC01NtG4tJidOWM8s3dbsuWMw2xm0jPbbidvO5MI1HIsLbcBl5YbOcYMvNuYDQyYGcwkeIFazA4AtTA2HMarhfHvtnqgFvZvQC3nks3OPySshZl322GgFh5jY54zB+zMbhCy5cyxYmbZbccNJA7zFD6cUZGcYHYDaEsCPr8cb97M+HZbtQF///ENBz4Y2NmbnU9/+OBDjQ1OLRggEawygVjlIGBPiuJRMApGwSgYGQAAWLBh/7+RG6wAAAAASUVORK5CYII=","orcid":"","institution":"Fundação Universitária de Cardiologia","correspondingAuthor":true,"prefix":"","firstName":"Marcia","middleName":"Moura","lastName":"Schmidt","suffix":""}],"badges":[],"createdAt":"2026-04-10 21:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9383132/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9383132/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108734095,"identity":"2bb7f134-1a46-4fff-997c-3669536ecdf0","added_by":"auto","created_at":"2026-05-07 19:48:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43963,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study according to maternal groups (with and without children with congenital heart disease)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9383132/v1/a7c3b963402d91d3b40f6f46.png"},{"id":108805850,"identity":"7434c275-8c8a-478e-8c9f-999d97ce0b2d","added_by":"auto","created_at":"2026-05-08 15:27:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":502256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9383132/v1/36fd48c9-c0bb-41bd-905d-a1fd24f112c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Maternal distress — guilt, depression, and anxiety among mothers of children with and without congenital heart disease","fulltext":[{"header":"HIGHLIGHTS","content":"\u003cp\u003e\u0026bull; Maternal guilt was highly prevalent (78%) across the total sample, regardless of the child\u0026rsquo;s clinical condition.\u003c/p\u003e\u003cp\u003e\u0026bull; Mothers of children without congenital heart disease were more likely to experience guilt than mothers of hospitalized children with the condition.\u003c/p\u003e\u003cp\u003e\u0026bull; Depressive symptoms significantly increased the likelihood of guilt, whereas anxiety was not significantly associated with this outcome.\u003c/p\u003e\u003cp\u003e\u0026bull; Contextual factors, including hospitalization and caregiving demands, appear to differentially shape maternal emotional experiences.\u003c/p\u003e\u003cp\u003e\u0026bull; The findings highlight the need for tailored psychological interventions addressing the specific needs of distinct groups of mothers.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003ePregnancy, childbirth, and the postpartum period involve profound physical and psychosocial transitions that evoke a wide range of emotional responses. During pregnancy, mothers construct mental representations of their child\u0026rsquo;s temperament, appearance, and health, contributing to early bonding (Fuertes et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Anxiety affects approximately 20%\u0026ndash;25% of pregnant women (Dom\u0026iacute;nguez-Sol\u0026iacute;s et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The transition to parenthood represents a normative developmental crisis within the family system (Bogdan et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and the quality of early mother\u0026ndash;infant interaction plays a critical role in socioemotional development (Darvishvand et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This period also involves biopsychosocial adjustments, prompting mothers to reflect on their caregiving roles (Gioia et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). When accompanied by a diagnosis of congenital malformation, however, this transition becomes significantly more complex, potentially destabilizing family functioning and parental mental health (Dom\u0026iacute;nguez-Sol\u0026iacute;s et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Bogdan et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong mothers of children with congenital heart disease (CHD), commonly reported emotions include guilt, anger, shock, and fear of the child\u0026rsquo;s death (Mutti et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Dandy et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The demands of intensive caregiving, uncertainty, and anticipatory grief often lead to emotional exhaustion and social isolation (Najafi et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Parents of children with cyanotic CHD frequently report grief, helplessness, and persistent sadness, regardless of prognosis (Cepuch et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). CHDs remain a leading cause of early childhood morbidity and mortality, affecting 6\u0026ndash;12 per 1,000 live births, with approximately half requiring surgery within the first year of life\u0026mdash;a period of heightened maternal vulnerability (Pedra et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Woolf-King et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Despite advances that reduced CHD-related infant mortality by more than 50% between 1990 and 2021 (Deng et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), caregiving demands remain substantial.\u003c/p\u003e \u003cp\u003eMothers are often primary caregivers during hospitalization, increasing susceptibility to anxiety and depression (Cepuch et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Pedra et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Maternal psychological distress may interfere with secure attachment formation and negatively affect child development (Kasparian et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Rodrigues et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Evidence underscores the importance of maternal mental health for neurodevelopmental outcomes in children with CHD (Cepuch et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Woolf-King et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Family-centered care models and supportive communication from healthcare professionals may mitigate distress and strengthen parental confidence (G\u0026oacute;mez-Cantarino et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Mu\u0026ntilde;oz-Pe\u0026ntilde;a et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDepressive and anxiety symptoms are frequently associated with guilt, a multifaceted construct shaped by moral and social contexts (Aquino and Medeiros, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Guilt encompasses subjective, objective, and temporal dimensions and can be assessed using the Multifactorial Guilt Scale (EMC). Although guilt may both contribute to and result from depressive symptoms, its causal direction remains unclear (Luck and Luck-Sikorski, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Women report more sources of guilt than men, particularly related to family and interpersonal domains (Luck and Luck-Sikorski, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Among parents of infants in intensive care, self-conscious emotions\u0026mdash;including guilt, shame, and fear of death\u0026mdash;have been shown to explain up to 28% of the variance in psychological distress, with chronic guilt demonstrating a significant association with mothers\u0026rsquo; distress (Barr, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and maternal depression and anxiety are inversely associated with children\u0026rsquo;s socioemotional development (Rogers et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExcessive guilt can undermine psychological well-being and caregiving capacity, precipitating depressive and anxiety symptoms. Despite its clinical and theoretical relevance, research on maternal guilt in the context of congenital heart disease (CHD) remains limited, particularly in low- and middle-income settings where access to psychosocial support may be constrained. Existing evidence suggests that psychological interventions may reduce anxiety, enhance parental confidence, and promote bonding (Ortinau et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Moreover, most existing studies have focused primarily on anxiety and depression, with comparatively less attention given to guilt as a distinct and potentially modifiable psychological construct. This gap is particularly relevant given the multidimensional nature of guilt and its potential role as both a risk factor and a maintaining mechanism of maternal psychological distress.\u003c/p\u003e \u003cp\u003eA deeper understanding of maternal guilt may contribute to improved screening strategies and the development of more targeted psychosocial interventions within pediatric cardiology settings. Clarifying how guilt interacts with depressive and anxiety symptoms may also support more comprehensive models of maternal mental health, integrating emotional, cognitive, and contextual dimensions. Such knowledge is essential to inform clinical practices that are sensitive not only to the child\u0026rsquo;s medical condition but also to the psychological needs of caregivers.\u003c/p\u003e \u003cp\u003eTherefore, the present study aims to: (1) examine the prevalence and dimensions of guilt among mothers of children with CHD compared to mothers of children without CHD; (2) investigate the association between guilt and symptoms of depression and anxiety; and (3) identify sociodemographic and clinical factors associated with maternal guilt. We hypothesize that mothers of children with CHD will present higher levels of guilt and psychological distress, and that guilt will be significantly associated with depressive and anxiety symptoms. By addressing these objectives, this study seeks to advance the understanding of maternal psychological distress in the context of chronic pediatric illness and to support the development of targeted, evidence-based interventions aimed at improving maternal well-being and strengthening family-centered care.\u003c/p\u003e \u003cp\u003eExcessive guilt can undermine psychological well-being and caregiving capacity, precipitating depressive and anxiety symptoms. Despite its relevance, research on maternal guilt in the context of CHD remains limited. Existing evidence suggests that psychological interventions may reduce anxiety, enhance parental confidence, and promote bonding (Ortinau et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Therefore, this study aims to examine the prevalence of guilt among mothers of children with congenital heart disease, explore its association with depressive and anxiety symptoms, and identify related factors, contributing to the development of targeted interventions to strengthen maternal mental health and family care quality.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis cross-sectional, descriptive, and comparative study employed a non-probabilistic sampling method. The sample comprised mothers aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years with children up to 9 years old (WHO, 2024) hospitalized in a reference cardiology hospital, where interviews were conducted during hospitalization. A comparison group consisted of mothers of children without congenital heart disease or other chronic diseases, recruited through preschools. Invitations, informed consent forms, and interview availability requests were distributed via these institutions, and consenting mothers were subsequently interviewed. This study complied with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the Institute of Cardiology (Brazil) under protocol number CAAE: 73187923.6.0000.5333. All participants provided written informed consent prior to study inclusion and subsequently completed the following standardized questionnaires:\u003c/p\u003e \u003cp\u003e \u003cb\u003eMultifactorial Guilt Scale (MFGS) \u0026ndash; Escala Multifatorial de Culpa (EMC) -\u003c/b\u003e Developed and validated for the Brazilian population by Aquino and Medeiros (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), the EMC is a 12-item instrument structured into three dimensions. Objective Guilt refers to concrete actions or omissions involving actual transgressions or violations of norms, which render the individual objectively guilty, regardless of subjective emotional experience (e.g., \u0026ldquo;I regret something I should not have done\u0026rdquo;). Subjective Guilt reflects an internal emotional state characterized by remorse, shame, guilt, and self-condemnation in response to thoughts, impulses, or behaviors perceived as inappropriate or morally wrong (e.g., \u0026ldquo;I feel guilty for having bad thoughts\u0026rdquo;). Temporal Guilt is associated with the human experience of time constraints and role overload, reflecting guilt related to insufficient time devoted to family or significant others (e.g., \u0026ldquo;I usually feel guilty for not having time for the people I love\u0026rdquo;)\u003c/p\u003e \u003cp\u003e \u003cb\u003eBeck Depression Inventory\u0026ndash;II (BDI-II) -\u003c/b\u003e The Beck Depression Inventory\u0026ndash;II (BDI-II) is a self-report instrument validated for the Brazilian population, consisting of 21 items that assess depressive symptoms experienced over the previous week. Total scores range from 0 to 63 and are classified as follows: 0\u0026ndash;13 (minimal or no depression), 14\u0026ndash;19 (mild depression), 20\u0026ndash;28 (moderate depression), and 29\u0026ndash;63 (severe depression) Gomes-Oliveira et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBeck Anxiety Inventory (BAI) -\u003c/b\u003e The Beck Anxiety Inventory (BAI), translated and validated in Brazil, consists of 21 items that reflect the physical, emotional, and cognitive symptoms of anxiety. Each item includes four response options indicating increasing levels of symptom severity, ranging from 0 to 3. The total score ranges from 0 to 63, allowing classification of anxiety levels as follows: 0\u0026ndash;10 (minimal anxiety), 11\u0026ndash;19 (mild anxiety), 20\u0026ndash;30 (moderate anxiety), and 31\u0026ndash;63 (severe anxiety) (Cunha \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe required sample size was estimated to detect a difference in the prevalence of depression between mothers with and without guilt. A total of 123 participants were required, allocated in a 1:2 ratio (41 in the guilt group and 82 in the no-guilt group). The calculation assumed a statistical power of 80%, a two-sided significance level of 5%, and expected prevalence rates of 25% and 5%, respectively, based on Luck and Luck-Sikorski (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The estimation was performed using the online sample size calculator provided by PSS Health (Borges et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCategorical variables were described as absolute and relative frequencies, and continuous variables as means and standard deviations. Group comparisons were performed using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate, for categorical variables, and the independent samples Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test for continuous variables, after assessment of distributional assumptions. To examine guilt levels, total scores from the Multifactorial Guilt Scale (EMC) were categorized according to the sample median. Scores were dichotomized into no guilt (0\u0026ndash;26 points) and presence of guilt (\u0026ge;\u0026thinsp;27 points), and further classified into mild (27\u0026ndash;33 points), moderate (34\u0026ndash;38 points), and severe guilt (39\u0026ndash;60 points). Crude and adjusted associations between independent variables and the presence of guilt were estimated using Poisson regression with robust variance to obtain prevalence ratios (PR) and corresponding 95% confidence intervals (95% CI). Variables with \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in the bivariate analyses were considered eligible for inclusion in the multivariable model. Statistical significance was defined as \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were performed using IBM SPSS Statistics.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eBetween September 2023 and February 2025, 242 children with congenital heart disease were admitted to the pediatric ward or intensive care unit, of whom 135 were accompanied by their mothers, and 123 were included in the case group. For the comparison group, 179 mothers were contacted through school referrals; 135 responded, resulting in a final sample of 123 mothers, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mothers of children with congenital heart disease were predominantly White (79.7%), had a partner (39% married and 17.1% in a stable union), and had completed secondary or technical education (42.3%). Most participants were engaged in paid employment (56.9%), belonged to low-income socioeconomic groups (64.2%), and approximately one-third resided in the metropolitan region of Porto Alegre/Brazil (29.5%). Half of the mothers (50.4%) had previously undergone psychological counseling, and 22% had received psychiatric care at some point in their lives. Additionally, 25.2% were using psychotropic medication. The children had a mean age of 4.8 years, and regarding their medical conditions, 78.9% had acyanotic congenital heart disease (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMothers in the group without congenital heart disease were predominantly White (91.1%), had a partner (52.8% married and 24.4% in a stable union), 18.5% had completed upper secondary and the remaining participants had completed tertiary education. Most participants were engaged in paid employment (85.4%), and a smaller proportion than in the other group belonged to low-income socioeconomic groups (29.3%). Additionally, 65.3% resided in the metropolitan region of Porto Alegre, Brazil. Half of the mothers (50.4%) had previously undergone psychological counseling, and 24.4% had received psychiatric care at some point in their lives. Additionally, 24.4% were using psychotropic medication. The children had a mean age of 6.2 years and had no congenital heart disease or other chronic condition (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Sociodemographic and psychological characteristics of mothers of children with and without congenital heart disease\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003echildren with CHD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;123\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003echildren without CHD n\u0026thinsp;=\u0026thinsp;123\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (91.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHad a partner, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of study, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.23\u0026thinsp;\u0026plusmn;\u0026thinsp;8.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (85.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow-income, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (64.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan region, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychological counseling, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (50.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (50.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychiatric care, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing psychotropic medication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children, count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u0026rsquo;s age, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.18\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeart disease classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcyanotic congenital heart disease n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (78,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychological Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGuilt\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEMC Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.96\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.90\u0026thinsp;\u0026plusmn;\u0026thinsp;7.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective guilt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObjective guilt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.12\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemporal guilt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.31\u0026thinsp;\u0026plusmn;\u0026thinsp;04.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.78\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.10\u0026thinsp;\u0026plusmn;\u0026thinsp;8.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.52\u0026thinsp;\u0026plusmn;\u0026thinsp;8.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (50.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.18\u0026thinsp;\u0026plusmn;\u0026thinsp;10.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEMC - Multifactorial Guilt Scale; BDI- Beck Depression inventory; BAI \u0026ndash; Beck anxiety Inventory.\u003c/p\u003e \u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, we observed significant differences in sociodemographic characteristics such as age, race, years of education, number of children, and whether the mothers lived with a partner. We also found that mothers of children with congenital heart disease were less likely to be engaged in paid employment, more frequently lived outside the metropolitan region, and more commonly belonged to low-income socioeconomic groups. The age of the children also differed significantly, with those with heart disease being younger.\u003c/p\u003e \u003cp\u003eRegarding psychological characteristics, mothers of children with congenital heart disease exhibited lower levels of guilt across all dimensions and higher anxiety compared with the others. Depression levels were similar in both groups. Given the sociodemographic differences identified in the sample, we proceeded to analyze guilt and associated factors. Based on the median guilt score, we examined two groups of mothers: those with guilt (\u0026gt;\u0026thinsp;26 points) and those without guilt (\u0026le;\u0026thinsp;26 points).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and psychological characteristics based on mothers\u0026rsquo; guilt levels\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWith guilt\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;192 (78%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithout Guilt\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;54 (22%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e166 (86.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (81.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a partner, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e130 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of study, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e141 (73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic classes D e E, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e85 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan region, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e94 (49.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychological counseling, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e101 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychiatric care, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e50 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing psychotropic medication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children, count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u0026rsquo;s age, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren with congenital heart disease, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e42 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychological Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.81\u0026thinsp;\u0026plusmn;\u0026thinsp;9.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnsent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e37 (68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e14 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.38\u0026thinsp;\u0026plusmn;\u0026thinsp;11.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11.67\u0026thinsp;\u0026plusmn;\u0026thinsp;9.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e28 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEMC - Multifactorial Guilt Scale; BDI- Beck Depression inventory; BAI \u0026ndash; Beck anxiety Inventory.\u003c/p\u003e \u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the factors associated with guilt were years of education\u0026mdash;with higher educational attainment in the group with guilt\u0026mdash;prior psychiatric follow-up, and psychotropic medication use, both of which were more frequent in this group. Similarly, mean depression and anxiety scores were higher in the guilt group. Both the total scores and the categorical classifications of the BDI and BAI were statistically significant. It was also observed that, in the guilt group, there were fewer mothers of children with congenital heart disease (42.2% vs. 77.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, we present the factors associated with guilt. In addition to the variables that were statistically significant between mothers with and without guilt, we included in the model all sociodemographic variables that differed between mothers of children with and without congenital heart disease. Among all variables, the mothers\u0026rsquo; group and depression were the factors associated with guilt.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of factors associated with guilt\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors associated with guilt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB (EXP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% confidence interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep*\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers in the non-CHD group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.145\u0026ndash;1.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.776\u0026ndash;1.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic Class D and E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.913\u0026ndash;1.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLives in a metropolitan region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.980\u0026ndash;1.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.967\u0026ndash;1.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.863\u0026ndash;1082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychiatric care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u0026ndash;1.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergone psychological counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.857\u0026ndash;1060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.990\u0026ndash;1.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.980\u0026ndash;0.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYaers of study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.994\u0026ndash;1.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.990\u0026ndash;1.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.990\u0026thinsp;=\u0026thinsp;1.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.980\u0026ndash;1083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen analyzing only the group of mothers and the severity of anxiety and depression, we observed that mothers of children without congenital heart disease had a 35% higher likelihood of experiencing guilt compared with those whose children had heart disease. Having mild, moderate, or severe depression increased the likelihood of guilt by 21% to 29%. Anxiety, however, was not associated with guilt (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between mothers\u0026rsquo; group, levels of depression and anxiety, and guilt\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors associated with guilt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB (EXP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervalo de 95% de confian\u0026ccedil;a\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP*\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers in the non-CHD group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.218\u0026ndash;1.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDepression\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.082\u0026ndash;1.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.123\u0026ndash;1.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.101\u0026ndash;1.506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnxiety\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.914\u0026ndash;1.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.993\u0026ndash;1.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.982\u0026ndash;1.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION AND CONCLUSIONS","content":"\u003cp\u003eThe present findings indicate that guilt was highly prevalent, affecting 78% of the sample. Although present in both groups, it was significantly less frequent among mothers of children with congenital heart disease (CHD) than among mothers of children without chronic conditions. Depressive symptoms were strongly associated with guilt, increasing its likelihood by more than 20%, reinforcing the established link between self-blame and depression.\u003c/p\u003e \u003cp\u003eAt first glance, lower guilt levels among mothers of children with CHD may seem unexpected given the clinical severity and emotional burden of chronic illness. However, this result can be understood within the hospitalization context. Most children with CHD were admitted to pediatric units requiring continuous caregiver presence, a role predominantly assumed by mothers. Sustained involvement in daily care and decision-making may enhance maternal perceptions of competence and efficacy, thereby mitigating guilt. Continuous engagement may also strengthen the mother\u0026ndash;child bond, consistent with family-centered care principles (G\u0026oacute;mez-Cantarino et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, professional guidance within the hospital setting may serve as a temporary support network, buffering excessive self-blame. Conversely, mothers of children without CHD may be more exposed to socially constructed and often unattainable ideals of motherhood, intensifying self-critical cognitions and guilt (Hubert and Aujoulat, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These findings underscore the role of contextual and sociocultural factors in shaping maternal emotional experiences.\u003c/p\u003e \u003cp\u003ePerceived maternal efficacy\u0026mdash;how mothers interpret the impact of their caregiving\u0026mdash;was closely related to guilt and parental competence. When distorted, such perceptions increase the risk of parental stress (Mu\u0026ntilde;oz-Pe\u0026ntilde;a et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In this study, higher guilt levels were associated with greater depressive symptomatology, particularly among mothers of children without CHD, suggesting a possible pattern of maternal burnout even in the context of healthy children. As noted by Hubert and Aujoulat (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), mothers of healthy children often overinvest in the maternal role, attempting to simultaneously manage multiple responsibilities, which may foster persistent inadequacy and psychological distress. The clinical relevance of these findings is reinforced by the fact that, among mothers reporting guilt, 50% had received psychological care, 26% psychiatric follow-up, and 28% had used psychotropic medication. These results also raise concerns that mothers of children with CHD may experience increased guilt and depressive symptoms after hospital discharge, when the demands of complex home-based care are added to routine parenting responsibilities, potentially exacerbating emotional overload if perceptions of competence decline.\u003c/p\u003e \u003cp\u003eAnother relevant finding was the high proportion of paid employment among mothers of children without congenital heart disease (85.4%), which may partially explain their higher levels of guilt. Tohme and Abi-Habib (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) note that guilt in working mothers is often linked to role overload, encompassing professional demands in addition to childcare and household responsibilities. In contrast, only 56.9% of mothers of children with congenital heart disease were employed, consistent with prior literature indicating that these mothers frequently assume primary caregiving and follow-up responsibilities, often withdrawing from the workforce (Najafi et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, leaving paid work may also increase vulnerability to depressive symptoms, as only 36.6% of mothers of children with congenital heart disease were free of depressive symptomatology. Regardless of employment status, mothers typically remain primarily responsible for domestic tasks and childcare. Those engaged in paid work\u0026mdash;particularly without adequate support\u0026mdash;may perceive greater difficulty in balancing competing demands, and unmet expectations in these domains have been associated with heightened guilt and stress (Coogan and Chen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study showed that depressive symptoms\u0026mdash;mild, moderate, or severe\u0026mdash;increased the likelihood of experiencing guilt by 21% to 29%. This association may be understood in light of Beck\u0026rsquo;s cognitive triad, characterized by negative views of the self, the world, and the future, which can undermine perceived self-efficacy and intensify guilt (Mu\u0026ntilde;oz-Pe\u0026ntilde;a et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Evidence also suggests that women report more sources of guilt than men. In a 2022 study, 255 male participants reported 573 reasons for guilt, whereas 346 female participants reported 926 reasons, most related to their children (Luck and Luck-Sikorski, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Maternal guilt is thus embedded in a social discourse that promotes the idealized and often unattainable image of the \u0026ldquo;perfect mother.\u0026rdquo; The gap between social expectations and lived experience may foster feelings of failure, exhaustion, and depressive symptoms (Hubert and Aujoulat, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Law et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong mothers of children with congenital heart disease, depressive and anxiety symptoms are generally more prevalent (Mutti et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In that study, 74% of these mothers reported anxiety symptoms (30.1% mild, 29.3% moderate, 14.6% severe), compared with 43.8% among mothers of children without the condition. This pattern is consistent with prior research linking the diagnosis of a severe pediatric illness to elevated anxiety (Oftedal et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Woolf-King et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Dandy et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Hospitalization\u0026mdash;requiring assimilation of complex medical information, anticipation of procedures, and coping with postoperative recovery\u0026mdash;may further intensify distress (Woolf-King et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, no association was found between guilt and anxiety in the present study, in line with Fergus et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), who reported a stronger relationship between shame and anxiety than between guilt and anxiety.\u003c/p\u003e \u003cp\u003eContrary to our initial hypothesis that mothers of children with CHD would present higher levels of guilt and psychological distress, the present findings revealed a more nuanced pattern. While psychological distress\u0026mdash;particularly depressive symptoms\u0026mdash;was indeed strongly associated with guilt, mothers of children with CHD did not exhibit higher levels of guilt compared to mothers of children without chronic conditions. This partially refutes our hypothesis and suggests that guilt may not be solely determined by the severity of the child\u0026rsquo;s clinical condition, but rather by contextual, cognitive, and sociocultural factors.\u003c/p\u003e \u003cp\u003eThe hypothesis regarding the association between guilt and depressive and anxiety symptoms was only partially supported: a robust relationship was observed between guilt and depression, whereas no significant association was found with anxiety. These results reinforce the conceptualization of guilt as more closely aligned with depressive cognitive patterns, such as self-blame and negative self-evaluation, than with anxiety-related processes.\u003c/p\u003e \u003cp\u003eFurthermore, the lower levels of guilt observed among mothers of children with CHD may reflect the buffering effects of structured care environments, increased maternal involvement, and professional support, which can enhance perceived maternal efficacy. In contrast, mothers of children without chronic conditions may be more vulnerable to internalized social expectations and idealized standards of motherhood, contributing to heightened guilt despite the absence of a medical condition. Together, these findings highlight the importance of moving beyond disease-centered assumptions and considering the broader psychosocial context when examining maternal emotional experiences.\u003c/p\u003e \u003cp\u003eOne limitation of this study concerns the subjective nature of psychological constructs and the reliance on self-report instruments, which may not fully capture the complexity of emotional experiences. Sociodemographic differences between groups, although statistically adjusted, may also have influenced the results. Additionally, voluntary participation among school-recruited mothers may have introduced selection bias, as the topic of guilt could have attracted those more affected by this feeling. The inclusion of a comparison group strengthened contextual interpretation; however, the fact that many hospitalized children were not accompanied by their mothers during the interview period may have introduced further bias, since the reasons for maternal absence during an average week of hospitalization remain unknown.\u003c/p\u003e \u003cp\u003eIn this cross-sectional comparative study based on real-world data, maternal guilt was highly prevalent, affecting 78% of the sample. Mothers of children without congenital heart disease were more likely to report guilt, and depressive symptoms significantly increased its likelihood. Although anxiety was more frequent among mothers of hospitalized children, it was not associated with guilt. These findings underscore the importance of tailored psychological interventions that address the specific contextual and emotional needs of each group and may also be applicable to mothers of children with other chronic conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo all the mothers who were willing to share their feelings with us, our gratitude.\u003cbr\u003e\u0026nbsp;To CAPES (Coordena\u0026ccedil;\u0026atilde;o de Aperfei\u0026ccedil;oamento de Pessoal de N\u0026iacute;vel Superior), a foundation linked to the Brazilian Ministry of Education (MEC), which provided the master\u0026apos;s and doctoral scholarships; and to CNPq (Conselho Nacional de Desenvolvimento Cient\u0026iacute;fico e Tecnol\u0026oacute;gico), which provided the undergraduate research scholarship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR.C.P. Conception and design of the study; methodological development; data collection; statistical analysis; data interpretation; manuscript drafting; responsibility for the integrity of the data; final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003eD.R.V. Data collection; data interpretation; critical revision of the manuscript for important intellectual content; responsibility for the integrity of the data; final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003eA.P.M. Data collection; responsibility for the integrity and accuracy of the data; final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003eM.M.S. Conception and design of the study; data interpretation; statistical analysis; critical revision of the manuscript for important intellectual content; final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Informed Consent Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the institutional ethics committee under CAAE number 73187923.6.0000.5333 and was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants provided written informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study were collected using the REDCap\u0026reg; platform and are available in anonymized form at the Open Science Framework (OSF) repository (https://osf.io/gm5cn/). The dataset includes responses to the EMC (Multifactorial Guilt Scale), BDI-II, and BAI questionnaires. Access is unrestricted for research purposes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Aquino TAA, Medeiros B. 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J Am Heart Assoc. 2017;6(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.doi.org/10.1161/JAHA.116.004862\u003c/span\u003e\u003cspan address=\"http://www.10.1161/JAHA.116.004862\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mother child relationship, guilt, emotional depression, anxiety, congenital heart disease","lastPublishedDoi":"10.21203/rs.3.rs-9383132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9383132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To investigate the prevalence of guilt and its association with depressive and anxiety symptoms among mothers of children with congenital heart disease (CHD) accompanying their child’s hospitalization in a referral cardiology hospital, compared with mothers of children without CHD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis cross-sectional comparative study included 123 mothers of children with CHD and 123 mothers of children without CHD. Participants completed the Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory (BAI), and the Multifactorial Guilt Scale (MGS). Crude and adjusted associations between independent variables and the presence of guilt were estimated using Poisson regression with robust variance to calculate prevalence ratios (PRs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eGuilt was highly prevalent, affecting 78% of the total sample. Mothers of children with CHD reported lower levels of guilt but higher levels of anxiety compared with mothers of children without CHD, while depressive symptom levels were similar between groups. Mothers of children without CHD were 35% more likely to experience guilt. The presence of depressive symptoms—mild, moderate, or severe—increased the likelihood of guilt by 21% to 29%. Anxiety was not significantly associated with guilt.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eMaternal guilt was frequent and strongly associated with depressive symptoms, regardless of the child’s clinical condition. Differences between groups suggest that contextual and caregiving factors may influence emotional experiences. These findings emphasize the need for psychological interventions tailored to the specific profiles and support needs of each group of mothers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Maternal distress — guilt, depression, and anxiety among mothers of children with and without congenital heart disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 19:48:53","doi":"10.21203/rs.3.rs-9383132/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-23T02:07:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-23T02:05:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-14T19:20:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-14T17:33:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-04-14T17:22:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7e9d359-46a5-4a07-b0b9-3558543f5704","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T19:48:54+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 19:48:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9383132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9383132","identity":"rs-9383132","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}