Adverse Pregnancy Experiences and Antenatal Depression: Mediation by Stress and Anxiety

Adverse Pregnancy Experiences and Antenatal Depression: Mediation by Stress and Anxiety | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adverse Pregnancy Experiences and Antenatal Depression: Mediation by Stress and Anxiety Ziqi Guan, Jun Li, Zherui Lin, Leyi Zhang, Dan Ji, Yanan Huang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5323351/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Women experience a range of challenging emotions during pregnancy, such as anxiety and depression, especially for the woman with a history of adverse pregnant experience. This study investigates the mental health impact of negative pregnancy experiences on antenatal women, focusing on the relationships between negative pregnancy events, perceived stress, pregnancy-related anxiety, and depression. Methods A total of 2,307 pregnant women participated in this cross-sectional study. Data were collected from hospital outpatient obstetrics and gynecology clinics by online questionnaires. Results Perceived stress and pregnancy-related anxiety served as mediators linking otherwise weakly correlated negative pregnant experiences and antenatal depression. Significant differences in BMI were observed across subgroups, moderating the impact of negative pregnancy events on depression. Conclusions Our findings underscore the mediating effects of perceived stress, and pregnancy-related anxiety in the relationship of negative pregnant experiences and antenatal depression. Interventions should address multiple perspectives, focusing on alleviating stress and anxiety to improve the mental health and reproductive willingness of women with adverse pregnancy experiences adverse pregnancy experience depression stress pregnancy-related anxiety mediating effect Figures Figure 1 Figure 2 Introduction Adverse pregnancy history, such as preterm birth, miscarriage, stillbirth, elective abortions and induced abortion, represent prevalent health concerns (Shapiro et al., 2017 ). The incidence of miscarriage ranges from 15 to 20% of all recognized pregnancies worldwide (Mendes et al., 2024 ; Quenby et al., 2021 ). From 2015 to 2019, there was an annual global average of 73.3 million abortions, translating to a rate of 39 abortions per 1000 women aged 15–49 years (Bearak et al., 2020 ). Existing research indicates that an adverse pregnancy history may increase a woman’s risk of developing anxiety, depression, and posttraumatic stress disorder (PTSD) (Adler et al., 2007 ; Farren et al., 2020 ; Herbert et al., 2022 ). Numerous studies have demonstrated that adverse pregnancy histories are associated with psychological distress, which can significantly influence a woman’s mental health during subsequent pregnancies. Pregnancy itself is a period of heightened vulnerability to depression and anxiety, potentially exacerbated by fluctuations in neurotransmitters and hormonal variables (Osman & Bahri, 2019 ). Women with adverse pregnancy experiences often exhibit increased susceptibility to anxiety and depression (Gaudet, 2010 ; Gong et al., 2013 ). A meta-analysis involving over 35000 pregnant women who had experienced termination, prior pregnancy loss, or neonatal death revealed a moderate to significant effect on anxiety and depression (Hunter et al., 2017 ). Furthermore, rates of moderate-to-severe depression and anxiety were notably higher among women with a history of recurrent pregnancy loss (Eleje et al., 2024 ). Compared to women without such antecedents, those with histories of negative pregnancies report lower life quality and more pronounced symptoms of anxiety and depression during their subsequent pregnancies, necessitating more care and attention (Armstrong, 2004 ; Cote-Arsenault & Mahlangu, 1999 ; Couto et al., 2009 ; Kulshreshtha et al., 2023 ). Studies have found that women with a history of spontaneous abortion may have greater expectations to successful delivery and the reproduction of a healthy fetus, and they often experience heightened anxiety as a primary psychological response, followed by depression (Marcinko et al., 2011 ). Research in Anhui Province, China, has underscored the profound impact of pregnancy loss, with miscarried women frequently experiencing increased anxiety and depression in subsequent pregnancies due to concerns about their ability to carry a pregnancy to term (Gong et al., 2013 ).This highlights the importance of offering empathetic support and mental health resources to women with adverse pregnancy experiences, helping them in managing their emotions and approaching future pregnancies with reassurance and strength. In addition, Bayrampour et al. ( 2018 ) reviewed the literature on antenatal anxiety and identified previous pregnancy loss as a potential risk factor for increased antenatal anxiety. However, studies suggest that it is not necessarily the experience of abortion itself that increases the risk of depression, but rather the perception of the experience as potentially traumatic (Hamama et al., 2010 ). Depression during the antenatal period remains a relatively understudied dimension of mood disorders associated with childbearing, receiving considerably less attention compared to postnatal depression (Martin & Martin, 2021 ). Nevertheless, the significance of addressing antenatal depression cannot be understated, as any form of maternal depressive symptoms may adversely affect a mother’s psychological well-being and the quality of mother-infant bonding. Moreover, evidence indicates that antenatal depression is a robust predictor of subsequent postnatal depression (Beck, 2001 ). Multiple risk factors contribute to antenatal depression, including limited educational attainment, low socioeconomic status, unplanned pregnancies, prior experiences of abuse, low self-esteem, and heightened levels of anxiety, stress, or inadequate social support during pregnancy (Leigh & Milgrom, 2008 ; Míguez & Vázquez, 2021 ). In this study, the Edinburgh Postnatal Depression Scale (EPDS) was employed to assess antenatal depressive symptoms. Although originally designed for postpartum depression screening, the EPDS is also recognized for its reliability and validity in detecting prenatal depression (Murray & Cox, 1990 ). Perceived stress, defined as an individual’s perception of life situations as stressful, is notably prevalent among pregnant women (Horiuchi et al., 2018 ). In Thailand, the prevalence of perceived stress symptoms in antenatal pregnant women was found to be 23.6% (Thongsonnboon et al., 2020 ). Previous pregnancy loss has been linked to increased stress during subsequent pregnancies, with 88% of mothers reporting heightened stress levels due to prior loss (McCarthy et al., 2015 ; Armstrong, 2004 ). In Nigeria, women with a history of repeated pregnancy loss exhibit significantly higher stress levels (Eleje et al., 2024 ). However, research found that perceived stress is generally high among pregnant women, regardless of their adverse pregnancy experiences, and there is no significant difference in stress-coping mechanisms between these groups (Kulshreshtha et al., 2023 ; Van et al., 2023 ; Yilmaz & Beji, 2013 ). Pregnancy-related anxiety (PrA) is a complex emotional state encompassing fears and concerns about pregnancy, childbirth, the health of the fetus, physical appearance change, parent expectations, and social and financial issues related to pregnancy (Hadfield et al., 2022b ). A Europe-wide study reported significant variability in the incidence of prenatal anxiety across countries and regions, ranging from 7.7–36.5%, indicating that pregnancy-related anxiety is a critical issue that warrants attention (Val & Miguez, 2023 ). The ramifications of pregnancy anxiety extend to physical health, leading to complications such as pregnancy hypertension and mental disorders like prenatal and postnatal depression. These mental disorders can negatively affect maternal-fetal attachment and contribute to adverse neurodevelopmental, cognitive and behavioral outcomes in children, including low birth weight and preterm birth, which increase neonatal morbidity and mortality (Mikolajkow & Malyszczak, 2022 ; Shapiro et al., 2013 ). Anxiety during pregnancy is distinct from generalized anxiety disorder and depression, often not meeting the criteria for anxiety disorders (Brunton et al., 2015 ; Sinesi et al., 2019 ). Kulshreshtha et al. ( 2023 ) found that adverse pregnancy history differentially affects various types of anxiety. Pregnant women with unfavorable pregnancy experience are substantially more likely to experience pregnancy-specific anxiety, while general anxiety remains unaffected. Pregnant-related anxiety and depression symptoms are marginally linked with the impact of previous perinatal loss (Armstrong, 2004 ). Shapiro et al. ( 2017 ) approaches from the perspective of pregnancy, found that different types of adverse pregnancy history relate differently to pregnant-related anxiety at various pregnancy stages. Specifically, prior elective abortion was significantly associated with higher pregnancy anxiety scores in the first and second trimesters, and this trend continued into the third trimester (Shapiro et al., 2017 ). The contribution of general anxiety and depression to the variance in pregnancy-related anxiety scores was minimal (Brunton et al., 2019 ). International studies have further emphasized anxiety as one of the core risk factors for antenatal depression. A study in Australia identified antenatal depression, antenatal anxiety, major life events, low social support, and a history of depression as significant predictors of postnatal depression, with antenatal depression and anxiety being among the strongest predictors (Milgrom et al., 2008 ). Additionally, antenatal anxiety has been linked to postpartum suicidal ideation (SI), a precursor to suicide attempts among new mothers (Schafer et al., 2024 ). This association highlights the critical need to address prenatal anxiety to prevent severe postpartum mental health complications. This study aims to investigate the subjective perception of stress and pregnancy-related anxiety among pregnant women and explore their relationship with adverse pregnancy experience and depression, hypothesized a significant mediating effect between them. Currently, there is a lack of research exploring the interplay between adverse pregnancy experience, perceived stress, and pregnancy-related anxiety. Therefore, this study seeks to elucidate these relationships and their implications for the mental health of pregnant women and provide basis for developing clinical therapies. Methods Participants The mental health status of pregnant women is routinely assessed as a part of antenatal care visits. Since 2021, we set up a mental health surveillance system for pregnant women during pregnancy. Pregnant women were asked to scan a QR code and self-report their mental health status via mobile phone. To investigate mental health status in early pregnancy (gestational age < 14 weeks), we included all pregnant women who attended antenatal visits at the maternity and infant health hospital in Shanghai from July 5, 2021, to December 27, 2021. The following cases were excluded: (1) more than 20% missing items in any survey scale, (2) incorrectly filled scales, (3) filled wrong identity number, (4) repeatedly submitted. After applying these exclusion criteria, 2307 pregnant women remained. This study was approved by the Institutional Review Board of Changning Maternity & Infant Health Hospital (CNFBLLKT-2023-018), and the process met the medical standards. Measures Pregnancy-Related Anxiety Questionnaire (PrAQ) Pregnancy-related anxiety is a 13-item instrument designed to assess anxiety specifically related to pregnancy (Brunton et al., 2019 ). The questionnaire evaluates three key areas: self-concern, worry about fetal health, and worry about childbirth. Each item is rated on a 4-point scale (0 = no worry, 1 = occasionally worried, 3 = often worried, 4 = always worried), with a total possible score of 52. Higher scores indicate higher levels of pregnancy-related anxiety. A total score ≥ 24 is considered the cut-off for identifying significant anxiety. This scale has been translated into many languages and utilized in various countries and regions, consistently demonstrating good reliability and validity (Hadfield et al., 2022a ). The reliability, measured by Cronbach’s alpha, typically ranges from 0.70 to 0.85 (Mudra et al., 2019 ). Mudra et al. ( 2019 ) also demonstrated PrAQ-13 has strong construct validity, and effectively differentiates pregnancy-related anxiety from general anxiety, further supporting its discriminant validity. In this study, the Cronbach’s alpha for this scale was 0.824. Edinburgh Post Natal Depression Scale (EPDS) The Edinburgh Post Natal Depression Scale (EPDS) is a widely utilized and well-validated screening tool for detecting depressive symptoms in pregnant women worldwide (Cox et al., 1987 ; Gemmill et al., 2006 ). It exhibits a sensitivity of 65–100% and specificity of 49–100% (Eberhard-Gran et al., 2001 ). Research indicated that the EPDS is effective not only for postpartum depression but also for antenatal depression (Kozinszky & Dudas, 2015 ). A cut-off score of 13 was employed, with score ≥ 13 indicating probable depression (Matthey et al., 2006 ), The EPDS has been validated across diverse cultures and has demonstrated superiority to unstructured health professional assessment or routine care (Levis et al., 2020 ). Studies consistently report high internal consistency, with Cronbach’s alpha values typically ranging from 0.80 to 0.87, indicating good reliability (Shrestha et al., 2016 ). In this study, the Cronbach’s alpha for this scale was 0.710. Perceived stress status (PSS-14) Perceived stress status was assessed using the Chinese version of PSS-14, which consists of seven positive and seven negative items, and has been validated in Chinese medical residents and community residents (Huang et al., 2020 ; Shi et al., 2019 ). The PSS-14 measures whether respondents perceive their lives as unpredictable, uncontrollable, or overloaded (Cohen et al., 1983 ). Each item is rated on a 5-point scale from 0 (never) to 4 (very often). PSS scores are obtained by reversing the scores on the seven positive items (items 4, 5, 6, 7, 9, 10, and 13) and summing across all items. Higher scores indicate greater stress levels and a higher likelihood that environmental demands exceed an individual’s coping ability. The PSS-14 has strong internal consistency (α = 0.84 to 0.86) and good test-retest reliability ( r = 0.85 over a 2-day period, r = 0.55 over a 6-week period; Cohen et al. 1983 ). In this study, the Cronbach’s alpha for this scale was 0.713. Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics 28.0. Descriptive statistics, independent sample t -tests, and correlation tests were conducted. Median analyses were performed using the PROCESS macro (version 4.1 by Andrew F. Hayes) for SPSS with 5000 bootstrap samples. Results Description of demographic information Demographic information and group differences for perceived stress (PSS), Pregnancy-related anxiety (PrAQ), and Edinburgh Postnatal Depression Scale (EPDS) among the pregnant women are presented in Table 1 . The demographic variables include age, education, employment status, Body Mass Index (BMI), and four stressful pregnancy-related incidents: history of induced abortion, medical abortion, induced labor, and premature labor. These incidents were aggregated into a composite variable, “adverse pregnancy experience”, which indicates whether a pregnant woman has experienced any negative pregnancy experience. The average age of the participants is 31.85 ± 3.64 years, with 21.8% classified as elderly pregnant women (age ≥ 35). 32% of pregnant women are unhealthy on the BMI scale, and 32% of mothers had a negative pregnancy experience. The chi-square test identified significant differences in formation between groups with high and low education levels, as well as between those with and without advanced maternal age. These findings are clinically meaningful and warrant further discussion. Table 1 Demographic information for the pregnant women ( N = 2307) Variables Total N (%) PSS M ± SD PrAQ M ± SD EPDS M ± SD Age < 35 1803(78.2) 32.30 ± 6.99** 20.84 ± 4.55* 6.92 ± 4.22 ≥ 35 504(21.8) 31.37 ± 6.73** 19.82 ± 4.12* 6.82 ± 4.23 Education Primary school and below 6(0.3) 38.83 ± 2.99 27.00 ± 5.93** 11.50 ± 2.26** Middle school and high school 161(7.0) 36.11 ± 7.42** 21.47 ± 5.47** 8.58 ± 4.93** College 1673(72.5) 32.21 ± 6.83** 20.55 ± 4.41** 6.88 ± 4.17** Graduate school and higher 455(19.7) 30.18 ± 6.52** 20.49 ± 4.24** 6.34 ± 3.98** Not reported 12(0.5) Employment status Employed 2136(92.6) 32.01 ± 6.91 20.64 ± 4.48* 6.88 ± 4.18 Unemployed 171(7.4) 33.09 ± 7.27 20.33 ± 4.52* 7.25 ± 4.72 BMI Normal (18.5 ≤ BMI < 24.9) 1799(78.0) 31.97 ± 6.96 20.57 ± 4.46 6.84 ± 4.22 Underweight (BMI < 18.5) 214(9.3) 33.47 ± 6.81 21.04 ± 4.76 7.47 ± 4.46 Overweight (25 ≤ BMI < 29.9) 272(11.8) 31.90 ± 6.94 20.72 ± 4.44 7.03 ± 4.09 Obesity (BMI ≥ 30) 22(1.0) 30.82 ± 5.67 19.91 ± 3.62 5.41 ± 2.86 Induced abortion history No 1985(86.0) 32.07 ± 6.93 20.74 ± 4.53 6.91 ± 4.23 Yes 322(14.0) 32.26 ± 7.04 19.92 ± 4.10 6.88 ± 4.21 Medical abortion history No 1838(79.7) 31.84 ± 6.90 20.64 ± 4.47 6.80 ± 4.12 Yes 469(20.3) 33.09 ± 7.05 20.54 ± 4.52 7.30 ± 4.59 Induced labor history No 2263(98.1) 32.06 ± 6.92 20.62 ± 4.48 6.88 ± 4.21 Yes 44(1.9) 33.80 ± 7.87 20.68 ± 4.49 8.02 ± 4.75 Premature labor history No 2284(99.0) 32.06 ± 6.95 20.62 ± 4.48 6.89 ± 4.22 Yes 23(1.0) 35.83 ± 5.64 21.13 ± 4.65 8.00 ± 4.21 Total negative pregnancy experience No 1567(67.9) 31.73 ± 6.85** 20.72 ± 4.52 6.78 ± 4.10 Yes 740(32.1) 32.87 ± 7.08** 20.41 ± 4.38 7.17 ± 4.48 * p < 0.05, ** p < 0.01 Correlations among continuous variables The Pearson’s correlation analysis results are shown in Table 2 . Perceived stress was significantly correlated with negative pregnancy experiences ( r = 0.08, p < 0.05), pregnancy-related anxiety (r= -0.04, p < 0.05), and depression symptoms ( r = 0.05, p < 0,05). Pregnancy-related anxiety was significantly positively correlated with perceived stress ( r = 0.45, p < 0.05) and antenatal depression symptoms ( r = 0.50, p < 0.05). Additionally, antenatal depression was significantly correlated with perceived stress ( r = 0.60, p < 0.05). Table 2 Correlations among negative pregnancy experience, PSS, PrAQ, and EPDS M ± SD Negative pregnancy experience PSS PrAQ EPDS Negative pregnancy experience 0.47 ± 0.81 1 0.08** -0.04* 0.05 * PSS 32.09 ± 6.94 0.08** 1 0.45** 0.60** PrAQ 20.62 ± 4.48 -0.04* 0.45** 1 0.50** EPDS 6.90 ± 4.22 0.05* 0.60** 0.50** 1 * p < 0.05, ** p < 0.01 Mediating effects and moderating effects The direct relationship between APE and depression was significant by regression analysis with a coefficient of 0.05 ( p 0.05). However, the indirect paths were all significant. The indirect path from adverse pregnancy experience to EPDS via PSS (path a 1 *b 1 , a 1 = 0.66, b1 = 0.29, 95% CI = [0.09, 0.29]) indicated a significant mediating role of perceived stress. Similarly, the indirect path from adverse pregnancy experience to EPDS through PrAQ (path a 2 *b 2 , a 2 =-0.42, b 2 = 0.27, 95% CI = [-0.17, -0.06]) indicated a significant mediating role of pregnancy-related anxiety. Interestingly, the coefficients for the first half of this path (a 2 ) were positive, whereas the second half of the coefficients (b 2 ) were negative, suggesting a masking effect that warrants further discussion. Additionally, the third indirect path involving both PSS and PrAQ as mediator between adverse pregnancy experience and EPDS (a 1 *d 21 *b 2 , a 1 = 0.66, d 21 = 0.30, b 2 = 0.27, 95% CI = [0.02, 0.08]) was significant. This means that both perceived stress and pregnancy-related anxiety mediated the relationship between adverse pregnancy experiences and depression. The mediating model is illustrated in Fig. 1 . * p < 0.05, ** p < 0.01 We also identified a significant moderating effect of BMI on the relationship between adverse pregnancy experiences and depression ( R ² = 0.01, F = 4.04, p < 0.05). This indicates that the impact of adverse pregnancy experiences on depression varies depending on an individual’s BMI. Specifically, different BMI levels may either amplify or attenuate the risk of depression in response to these experiences. The moderating effect of BMI is presented separately in Fig. 2 . Discussion Declining birth rates have prompted many countries to implement policies that actively promote fertility. However, numerous women opt not to have children, driven by various factors. Research highlights that psychological stress and trauma stemming from adverse pregnancy experiences are among the primary contributors to this decision (Li et al., 2024 ). This study investigates the mental health of women who have encountered negative pregnancy experiences, with the goal of enhancing their well-being by exploring the associations between such experiences, perceived stress, anxiety, and depression, which may, in turn, influence their reproductive intentions. The findings of this study support the proposed hypothesis and are consistent with previous research, demonstrating that adverse pregnancy experiences are linked to depression in women within the first 14 weeks of gestation. This association is mediated by perceived stress and pregnancy-related anxiety. By analyzing and comparing the demographic data presented in Table 1 , it is evident that education level, age, and adverse pregnancy experiences significantly influence perceived stress, anxiety, and depression among antenatal women. Notably, while differences in mental health across various BMI subgroups were not statistically significant, our findings revealed that BMI significantly moderates the impact of adverse pregnancy experiences on depression. This indicates that BMI levels do not directly affect the mental health of pregnant women; rather, the influence of adverse pregnancy experiences on depression is contingent upon individual BMI levels. Among pregnant women who did not experience a negative pregnancy event, healthy BMI pregnant women had more depression, but among pregnant women who experienced a negative pregnancy event, pregnant women with unhealthy BMI values had higher levels of depression. Specifically, variations in BMI may alter the magnitude or direction of the risk posed by adverse pregnancy experiences on depression, underscoring BMI’s critical moderating role in this mental health process. The correlation analysis results presented in Table 2 reveal that adverse pregnancy events are significantly correlated with perceived stress, pregnancy-related anxiety, and depression, though the correlation coefficients are relatively low. However, the mediating coefficient is significant and relatively robust. Previous research has indicated similar issue that this represents a distinct type of mediating variable, capable of establishing an indirect connection between two variables that would otherwise exhibit no apparent relationship (Xin, & Chi, 2003 ). In this context, it can be interpreted as follows: the predictive effect of negative pregnancy events on depression is nearly negligible. However, through the mediating roles of perceived stress and pregnancy-related anxiety, an indirect influence can emerge. Meanwhile, perceived stress, pregnancy-related anxiety, and depression exhibit strong intercorrelations, with high correlation coefficients, indicating a significant positive relationship among these three variables. This suggests that these psychological factors are closely related and may influence each other in meaningful ways within the context of pregnancy. In the mediation model, the direct effect of negative pregnancy experiences on depression was not statistically significant, while the total effect and all three mediating pathways showed significant results. This suggests that depressive symptoms during pregnancy should be considered from a multidimensional perspective. Specifically, adverse pregnancy experiences do not directly cause antenatal depression. Instead, these experiences contribute to depressive symptoms indirectly, primarily through increased perceived stress and pregnancy-related anxiety. This highlights the importance of addressing both stress and anxiety in pregnant women as key mediators in the relationship between negative pregnancy experiences and the development of depression. By considering these mediating factors, interventions can be more effectively targeted to reduce the risk of antenatal depression. Consistent with previous research, pregnant women’s perceived stress significantly moderates depression induced by adverse pregnancy experiences in this study. After experiencing a negative pregnancy event, pregnant women face stress from a variety of sources, such as moral condemnation, relationship changes, physical pain, family conflicts, and psychological changes, etc. (Traylor et al., 2020 ). These perceived stressors can significantly contribute to depression in subsequent pregnancies. Therefore, psychological counselors dealing with pregnant women who have had negative pregnancy experiences should inquire about these negative experiences to explore and alleviate the sources of stress, potentially leading to better outcomes. Contrary to previous perceptions, our study revealed a negative correlation between negative pregnancy experiences and pregnancy-related anxiety at path a 2 , while path b 2 exhibit a positive correlation. This pattern suggests the presence of a masking effect in mediation. While negative pregnancy experiences might initially seem to reduce anxiety (possibly due to denial or a protective cognitive mechanism), they ultimately contribute to increased anxiety through other pathways. It seems like women with negative pregnancy experiences are less sensitive to the three factors of the Pregnancy-Related Anxiety Scale: concern for self, concern for the health of the fetus, and concern for childbirth. But the masking effect indicates that the true relationship between adverse pregnancy experiences and pregnancy-related anxiety may be more complex than previously understood. This finding underscores the importance of considering the intricate interplay between various psychological factors when assessing the impact of negative pregnancy experiences on mental health outcomes. This study has significant highlights. First, the data were collected directly from real-world clinical settings, ensuring that participants were engaged and provided responses that closely reflect actual conditions, thereby enhancing the ecological validity and accuracy of the findings. Second, the study’s robustness is supported by a substantial sample size, comprising 2,307 women over a period exceeding six months, which strengthens the reliability and generalizability of the results. Third, in contrast to existing research, this study extends its focus to the clinical applicability of the findings, emphasizing the importance of addressing stress sources and sensitivities among pregnant women with adverse pregnancy experiences. However, the study has certain limitations. As a cross-sectional design, it does not include longitudinal data tracking these women throughout the antenatal and postpartum periods, thus limiting causal inferences. Furthermore, the practical relevance of the proposed implications warrants further validation in additional clinical settings to assess their broader applicability. In conclusion, this study offers valuable insights into the mental health of pregnant women who have experienced adverse pregnancy events, as well as the underlying mechanisms that may impact their psychological well-being. It emphasizes the importance of addressing perceived stress and pregnancy-related anxiety to mitigate depression and enhance overall well-being. Declarations No potential conflict of interest was reported by the author(s). Ethics Approval and Consent to Participate This study was approved by the Institutional Review Board of Changning Maternity & Infant Health Hospital (CNFBLLKT-2023-018), and the procedures adhered to medical standards. All participants signed consent forms to participate in the study, and they were informed of their right to withdraw at any time. Consent for Publication All authors have reviewed the manuscript and given their consent for its publication in BMC Pregnancy and Childbirth . Each author has contributed significantly to the work and is accountable for the content of the article. Furthermore, the authors affirm that the content has not been previously published and is not under consideration for publication elsewhere. Availability of Data and Material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Fundings This study was supported by the STI 2030- Major Projects (Grant Number: 2021ZD0200500), East China Normal University Medicine and Health Joint Fund (2022JKXYD05001), Shanghai Dingbo-ECNU Project (Grant Number: DBYL-2022-HS), and Science and Technology Commission of Changning District, Shanghai (CNKW2022Y36). Authors’ Contributions Ziqi Guan wrote the main manuscript text and conducted the data analysis. Jun Li, Dan Ji, and Yanan Huang collected data and did administrative stuff. Zherui Lin, and Leyi Zhang did literature review and wrote manuscript text. Juzhe Xi and Wenli Fang designed the research and did administrative stuff. All authors reviewed the manuscript. Clinical Trail Not applicable. References Adler JM, Wagner JW, McAdams DP. Personality and the coherence of psychotherapy narratives [Article]. J Res Pers. 2007;41(6):1179–98. https://doi.org/10.1016/j.jrp.2007.02.006 . Armstrong DS. Impact of prior perinatal loss on subsequent pregnancies [Article]. Jognn-Journal Obstetric Gynecologic Neonatal Nurs. 2004;33(6):765–73. https://doi.org/10.1177/0884217504270714 . Bayrampour H, Vinturache A, Hetherington E, Lorenzetti DL, Tough S. Risk factors for antenatal anxiety: A systematic review of the literature [Review]. J Reproductive Infant Psychol. 2018;36(5):476–503. https://doi.org/10.1080/02646838.2018.1492097 . Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tuncalp O, Beavin C, Kwok L, Alkema L. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019 [Article]. Lancet Global Health. 2020;8(9):E1152–61. https://doi.org/10.1016/s2214-109x(20)30315-6 . Beck CT. Predictors of postpartum depression: an update. Nurs Res. 2001;50(5):275–85. Brunton R, Dryer R, Saliba A, Kohlhoff J. Re-examining pregnancy-related anxiety: A replication study [Article]. Women Birth. 2019;32(1):E131–7. https://doi.org/10.1016/j.wombi.2018.04.013 . Brunton RJ, Dryer R, Saliba A, Kohlhoff J. Pregnancy anxiety: A systematic review of current scales [Review]. J Affect Disord. 2015;176:24–34. https://doi.org/10.1016/j.jad.2015.01.039 . Brunton RJ, Dryer R, Saliba A, Kohlhoff J. The initial development of the Pregnancy-related Anxiety Scale. Women Birth. 2019;32(1):e118–30. Cohen S, Kamarck T, Mermelstein R. (1983). A global measure of perceived stress. J Health Soc Behav, 385–96. Cote-Arsenault D, Mahlangu N. (1999). Impact of perinatal loss on the subsequent pregnancy and self: women's experiences. Journal of obstetric, gynecologic, and neonatal nursing: JOGNN , 28 (3), 274–282. ://MEDLINE:10363539. Couto ER, Couto E, Vian B, Gregorio Z, Nomura ML, Zaccaria R, Passini Junior R. Quality of life, depression and anxiety among pregnant women with previous adverse pregnancy outcomes [Article]. Sao Paulo Med J. 2009;127(4):185–9. https://doi.org/10.1590/s1516-31802009000400002 . Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J psychiatry. 1987;150(6):782–6. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen O, S. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta psychiatrica Scandinavica. 2001;104(4):243–9. Eleje GU, Oguejiofor CB, Oriji SO, Ekwuazi KE, Ugwu EO, Igbodike EP, Malachy DE, Nwankwo EU, Onah CE, Ugboaja JO, Ikechebelu JI, Nwagha UI. Depression, anxiety, and stress and adverse pregnancy outcomes in pregnant women with history of recurrent pregnancy loss in Nigeria [Article]. Int J Psychiatry Med. 2024;59(3):303–24. https://doi.org/10.1177/00912174231199215 . Farren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, Al-Memar M, Tapp S, Van Calster B, Wynants L, Timmerman D, Bourne T. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study [Article]. Am J Obstet Gynecol. 2020;222(4):1–e22. https://doi.org/10.1016/j.ajog.2019.10.102 . Article 367.e. Gaudet C. Pregnancy after perinatal loss: association of grief, anxiety and attachment [Article]. J Reproductive Infant Psychol. 2010;28(3):240–51. https://doi.org/10.1080/02646830903487342 . Article Pii 922430955. Gemmill AW, Leigh B, Ericksen J, Milgrom J. A survey of the clinical acceptability of screening for postnatal depression in depressed and non-depressed women. BMC Public Health. 2006;6:1–8. Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study [Article]. Eur J Obstet Gynecol Reproductive Biology. 2013;166(1):30–6. https://doi.org/10.1016/j.ejogrb.2012.09.024 . Hadfield K, Akyirem S, Sartori L, Abdul-Latif A-M, Akaateba D, Bayrampour H, Daly A, Hadfield K, Abiiro GA. Measurement of pregnancy-related anxiety worldwide: a systematic review. BMC Pregnancy Childbirth. 2022a;22(1):331. Hadfield K, Akyirem S, Sartori L, Abdul-Latif A-M, Akaateba D, Bayrampour H, Daly A, Hadfield K, Abiiro GA. Measurement of pregnancy-related anxiety worldwide: a systematic review [Review]. BMC Pregnancy Childbirth. 2022b;22(1). Article 331. https://doi.org/10.1186/s12884-022-04661-8 . Hamama L, Rauch SAM, Sperlich M, Defever E, Seng JS, SPONTANEOUS OR ELECTIVE ABORTION AND RISK FOR POSTTRAUMATIC STRESS AND DEPRESSION DURING SUBSEQUENT PREGNANCY [Article]. Depress Anxiety. 2010;27(8):699–707. https://doi.org/10.1002/da.20714 . PREVIOUS EXPERIENCE OF. Herbert D, Young K, Pietrusinska M, MacBeth A. The mental health impact of perinatal loss: A systematic review and meta-analysis [Review]. J Affect Disord. 2022;297:118–29. https://doi.org/10.1016/j.jad.2021.10.026 . Horiuchi S, Tsuda A, Yoneda K, Aoki S. Mediating effects of perceived stress on the relationship of positivity with negative and positive affect [Article]. Psychol Res Behav Manage. 2018;11:299–303. https://doi.org/10.2147/prbm.S164761 . Huang F, Wang H, Wang Z, Zhang J, Du W, Su C, Jia X, Ouyang Y, Wang Y, Li L. Psychometric properties of the perceived stress scale in a community sample of Chinese. BMC Psychiatry. 2020;20:1–7. Hunter A, Tussis L, MacBeth A. The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis [Review]. J Affect Disord. 2017;223:153–64. https://doi.org/10.1016/j.jad.2017.07.004 . Kozinszky Z, Dudas RB. Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period. J Affect Disord. 2015;176:95–105. Kulshreshtha S, Siwatch S, Aggarwal N, Rohilla M, Grover S. Mental health issues in antenatal women with prior adverse pregnancy outcomes: Unmasking the mental anguish of rainbow pregnancy [Article]. Indian J Med Res. 2023;158(2):190–6. https://doi.org/10.4103/ijmr.ijmr_1241_21 . Leigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry. 2008;8:1–11. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. (2020). Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. bmj , 371 . Li Q, Yang R, Zhou Z, Qian W, Zhang J, Wu Z, Jin L, Wu X, Zhang C, Zheng B. Fertility history and intentions of married women, China. Bull World Health Organ. 2024;102(4):244. Marcinko VM, Marcinko D, Dordevic V, Oreskovic S. Anxiety and Depression in Pregnant Women with Previous History of Spontaneous Abortion [Article]. Coll Antropol. 2011;35:225–8. ://WOS:000289956500036. Martin CR, Martin CJH. Screening for antenatal depression (AND) using self-report questionnaires: Conceptual issues and measurement limitations. The Neuroscience of Depression. Elsevier; 2021. pp. 195–203. Matthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale–implications for clinical and research practice. Arch Women Ment Health. 2006;9:309–15. McCarthy FP, Moss-Morris R, Khashan AS, North RA, Baker PN, Dekker G, Poston L, McCowan LME, Walker JJ, Kenny LC, O'Donoghue K. Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. Bjog-an Int J Obstet Gynecol. 2015;122(13):1757–64. https://doi.org/10.1111/1471-0528.13233 . Mendes DCG, Fonseca A, Cameirao MS. The relationship between healthcare satisfaction after miscarriage and perinatal grief symptoms: A cross-sectional study on Portugal residents [Article]. Soc Sci Med. 2024. https://doi.org/10.1016/j.socscimed.2024.117037 ., 353, Article 117037. Míguez MC, Vázquez MB. Risk factors for antenatal depression: A review. World J Psychiatry. 2021;11(7):325. Mikolajkow A, Malyszczak K. Biological factors and consequences of pregnancy-related anxiety - What do we know so far? [Article]. Psychiatr Pol. 2022;56(6):1289–314. https://doi.org/10.12740/pp/144138 . Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J, Ericksen J, Ellwood D, Buist A. Antenatal risk factors for postnatal depression: A large prospective study [Article]. J Affect Disord. 2008;108(1–2):147–57. https://doi.org/10.1016/j.jad.2007.10.014 . Mudra S, Göbel A, Barthel D, Hecher K, Schulte-Markwort M, Goletzke J, Arck P, Diemert A. Psychometric properties of the German version of the pregnancy-related anxiety questionnaire-revised 2 (PRAQ-R2) in the third trimester of pregnancy. BMC Pregnancy Childbirth. 2019;19:1–9. Murray D, Cox JL. Screening for depression during pregnancy with the Edinburgh Depression Scale (EDDS). J reproductive infant Psychol. 1990;8(2):99–107. Osman NN, Bahri AI. Impact of Altered Hormonal and Neurochemical Levels on Depression Symptoms in Women During Pregnancy and Postpartum Period [Article]. J Biochem Technol. 2019;10(1):16–23. ://WOS:000466173600004. Quenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, Brosens JJ, Brewin J, Ramhorst R, Lucas ES, McCoy RC, Anderson R, Daher S, Regan L, Al-Memar M, Bourne T, MacIntyre DA, Rai R, Christiansen OB, Coomarasamy A. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss [Review]. Lancet. 2021;397(10285):1658–67. https://doi.org/10.1016/s0140-6736(21)00682-6 . Schafer KM, Mulligan E, Shapiro MO, Flynn H, Joiner T, Hajcak G. Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation. Anxiety Stress Coping. 2024;1–11. https://doi.org/10.1080/10615806.2024.2333377 . Shapiro GD, Fraser WD, Frasch MG, Seguin JR. Psychosocial stress in pregnancy and preterm birth: associations and mechanisms [Review]. J Perinat Med. 2013;41(6):631–45. https://doi.org/10.1515/jpm-2012-0295 . Shapiro GD, Seguin JR, Muckle G, Monnier P, Fraser WD. Previous pregnancy outcomes and subsequent pregnancy anxiety in a Quebec prospective cohort [Article]. J Psychosom Obstet Gynecol. 2017;38(2):121–32. https://doi.org/10.1080/0167482x.2016.1271979 . Shi C, Guo Y, Ma H, Zhang M. Psychometric validation of the 14-item perceived stress scale in Chinese medical residents. Curr Psychol. 2019;38:1428–34. Shrestha SD, Pradhan R, Tran TD, Gualano RC, Fisher JR. Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2016;16:1–19. Sinesi A, Maxwell M, O'Carroll R, Cheyne H. Anxiety scales used in pregnancy: systematic review [Review]. Bjpsych Open. 2019;5(1). https://doi.org/10.1192/bjo.2018.75 . Article e5. Thongsonnboon W, Kaewkiattikun K, Kerdcharoen N. Perceived Stress and Associated Factors Among Pregnant Women Attending Antenatal Care in Urban Thailand [Article]. Psychol Res Behav Manage. 2020;13:1115–22. https://doi.org/10.2147/prbm.S290196 . Traylor CS, Johnson JD, Kimmel MC, Manuck TA. Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. Am J Obstet Gynecol MFM. 2020;2(4):100229. Val A, Miguez MC. Prevalence of Antenatal Anxiety in European Women: A Literature Review [Review]. Int J Environ Res Public Health. 2023;20(2). Article 1098. https://doi.org/10.3390/ijerph20021098 . Van P, Gay CL, Lee KA. Prior pregnancy loss and sleep experience during subsequent pregnancy [Article]. Sleep Health. 2023;9(1):33–9. https://doi.org/10.1016/j.sleh.2022.11.004 . Xin Z, Chi L. The relationship between family functioning and children's loneliness: the role of mediators. Acta Physiol Sinica. 2003;35(2):216–21. (Chinese version). Yilmaz SD, Beji NK. Effects of perinatal loss on current pregnancy in Turkey [Article]. Midwifery. 2013;29(11):1272–7. https://doi.org/10.1016/j.midw.2012.11.015 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5323351","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":372604466,"identity":"839983f3-2038-483c-9a83-605cc8ffd8a5","order_by":0,"name":"Ziqi Guan","email":"","orcid":"","institution":"East China Normal University","correspondingAuthor":false,"prefix":"","firstName":"Ziqi","middleName":"","lastName":"Guan","suffix":""},{"id":372604467,"identity":"653a6e9d-dc19-4b6c-bee7-0a3c2aa1cb64","order_by":1,"name":"Jun Li","email":"","orcid":"","institution":"Shanghai Changning Maternity and Infant Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Li","suffix":""},{"id":372604468,"identity":"213cc039-fced-4ebf-bd2f-239030d5d615","order_by":2,"name":"Zherui Lin","email":"","orcid":"","institution":"East China Normal University","correspondingAuthor":false,"prefix":"","firstName":"Zherui","middleName":"","lastName":"Lin","suffix":""},{"id":372604469,"identity":"402fc21f-4bf0-47c7-a12e-88b4ff370b06","order_by":3,"name":"Leyi Zhang","email":"","orcid":"","institution":"East China Normal University","correspondingAuthor":false,"prefix":"","firstName":"Leyi","middleName":"","lastName":"Zhang","suffix":""},{"id":372604470,"identity":"c913a06a-d7e2-4b09-b72f-ae1e8ba0718c","order_by":4,"name":"Dan Ji","email":"","orcid":"","institution":"Shanghai Changning Maternity and Infant Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Ji","suffix":""},{"id":372604471,"identity":"b82dc82c-9a3f-41d0-b243-6f03ffadc7af","order_by":5,"name":"Yanan Huang","email":"","orcid":"","institution":"Shanghai Changning Maternity and Infant Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanan","middleName":"","lastName":"Huang","suffix":""},{"id":372604472,"identity":"6d50a8b5-932f-46d9-82d6-57eb713a918a","order_by":6,"name":"Juzhe Xi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYBACxgYGhgMf0AQIazk4gyQtIMDMQ5IW5v4zhodtd9QlNrA3P3vMw2Aju+EA87MH+B12LOFw7pnDiQ08x8yNeRjSjDccYDM3wKulsfnA4dy2A4kNEjls0jwMhxM3HOBhk8CrpZmx4bBlG9Bh8m9AWv4ToaWN+cBhIAG0hQek5QARWnrYEg72njls3MaTZiY5xyDZeOZhNjO8Wgz7zxh/+LmjTraf/fAziTcVdrJ9x5uf4dfSwACOC8c2MBcUVMz41AOBPANEiz0BdaNgFIyCUTCSAQDAjEevtg+VPQAAAABJRU5ErkJggg==","orcid":"","institution":"East China Normal University","correspondingAuthor":true,"prefix":"","firstName":"Juzhe","middleName":"","lastName":"Xi","suffix":""},{"id":372604473,"identity":"ad76db7a-2baa-4b50-afb8-1a07fbf80f9d","order_by":7,"name":"Wenli Fang","email":"","orcid":"","institution":"East China Normal University","correspondingAuthor":false,"prefix":"","firstName":"Wenli","middleName":"","lastName":"Fang","suffix":""}],"badges":[],"createdAt":"2024-10-24 06:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5323351/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5323351/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68360865,"identity":"52028005-838b-4fcf-81cd-8945aba090a1","added_by":"auto","created_at":"2024-11-06 12:13:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":237456,"visible":true,"origin":"","legend":"\u003cp\u003eThe results of the mediation analysis.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5323351/v1/1c02c1a380fd52a840794b3b.png"},{"id":68360863,"identity":"c195e245-3913-4578-ae7b-42143e08fe3c","added_by":"auto","created_at":"2024-11-06 12:13:54","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128561,"visible":true,"origin":"","legend":"\u003cp\u003eThe moderating effect of BMI in the relationship between adverse pregnancy experience and depression.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5323351/v1/e77811d0f7a0ac074aa6060a.jpeg"},{"id":70727313,"identity":"6584a78d-b996-4276-b9b1-65a6425ea38e","added_by":"auto","created_at":"2024-12-06 04:47:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":893713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5323351/v1/7f504a14-e3ad-44b6-a7af-17311987244a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adverse Pregnancy Experiences and Antenatal Depression: Mediation by Stress and Anxiety","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdverse pregnancy history, such as preterm birth, miscarriage, stillbirth, elective abortions and induced abortion, represent prevalent health concerns (Shapiro et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The incidence of miscarriage ranges from 15 to 20% of all recognized pregnancies worldwide (Mendes et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Quenby et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). From 2015 to 2019, there was an annual global average of 73.3\u0026nbsp;million abortions, translating to a rate of 39 abortions per 1000 women aged 15\u0026ndash;49 years (Bearak et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Existing research indicates that an adverse pregnancy history may increase a woman\u0026rsquo;s risk of developing anxiety, depression, and posttraumatic stress disorder (PTSD) (Adler et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Farren et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Herbert et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNumerous studies have demonstrated that adverse pregnancy histories are associated with psychological distress, which can significantly influence a woman\u0026rsquo;s mental health during subsequent pregnancies. Pregnancy itself is a period of heightened vulnerability to depression and anxiety, potentially exacerbated by fluctuations in neurotransmitters and hormonal variables (Osman \u0026amp; Bahri, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Women with adverse pregnancy experiences often exhibit increased susceptibility to anxiety and depression (Gaudet, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Gong et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). A meta-analysis involving over 35000 pregnant women who had experienced termination, prior pregnancy loss, or neonatal death revealed a moderate to significant effect on anxiety and depression (Hunter et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Furthermore, rates of moderate-to-severe depression and anxiety were notably higher among women with a history of recurrent pregnancy loss (Eleje et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Compared to women without such antecedents, those with histories of negative pregnancies report lower life quality and more pronounced symptoms of anxiety and depression during their subsequent pregnancies, necessitating more care and attention (Armstrong, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Cote-Arsenault \u0026amp; Mahlangu, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Couto et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Kulshreshtha et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Studies have found that women with a history of spontaneous abortion may have greater expectations to successful delivery and the reproduction of a healthy fetus, and they often experience heightened anxiety as a primary psychological response, followed by depression (Marcinko et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Research in Anhui Province, China, has underscored the profound impact of pregnancy loss, with miscarried women frequently experiencing increased anxiety and depression in subsequent pregnancies due to concerns about their ability to carry a pregnancy to term (Gong et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).This highlights the importance of offering empathetic support and mental health resources to women with adverse pregnancy experiences, helping them in managing their emotions and approaching future pregnancies with reassurance and strength. In addition, Bayrampour et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reviewed the literature on antenatal anxiety and identified previous pregnancy loss as a potential risk factor for increased antenatal anxiety. However, studies suggest that it is not necessarily the experience of abortion itself that increases the risk of depression, but rather the perception of the experience as potentially traumatic (Hamama et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDepression during the antenatal period remains a relatively understudied dimension of mood disorders associated with childbearing, receiving considerably less attention compared to postnatal depression (Martin \u0026amp; Martin, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Nevertheless, the significance of addressing antenatal depression cannot be understated, as any form of maternal depressive symptoms may adversely affect a mother\u0026rsquo;s psychological well-being and the quality of mother-infant bonding. Moreover, evidence indicates that antenatal depression is a robust predictor of subsequent postnatal depression (Beck, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Multiple risk factors contribute to antenatal depression, including limited educational attainment, low socioeconomic status, unplanned pregnancies, prior experiences of abuse, low self-esteem, and heightened levels of anxiety, stress, or inadequate social support during pregnancy (Leigh \u0026amp; Milgrom, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; M\u0026iacute;guez \u0026amp; V\u0026aacute;zquez, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In this study, the Edinburgh Postnatal Depression Scale (EPDS) was employed to assess antenatal depressive symptoms. Although originally designed for postpartum depression screening, the EPDS is also recognized for its reliability and validity in detecting prenatal depression (Murray \u0026amp; Cox, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1990\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerceived stress, defined as an individual\u0026rsquo;s perception of life situations as stressful, is notably prevalent among pregnant women (Horiuchi et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In Thailand, the prevalence of perceived stress symptoms in antenatal pregnant women was found to be 23.6% (Thongsonnboon et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Previous pregnancy loss has been linked to increased stress during subsequent pregnancies, with 88% of mothers reporting heightened stress levels due to prior loss (McCarthy et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Armstrong, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). In Nigeria, women with a history of repeated pregnancy loss exhibit significantly higher stress levels (Eleje et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, research found that perceived stress is generally high among pregnant women, regardless of their adverse pregnancy experiences, and there is no significant difference in stress-coping mechanisms between these groups (Kulshreshtha et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Van et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Yilmaz \u0026amp; Beji, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePregnancy-related anxiety (PrA) is a complex emotional state encompassing fears and concerns about pregnancy, childbirth, the health of the fetus, physical appearance change, parent expectations, and social and financial issues related to pregnancy (Hadfield et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022b\u003c/span\u003e). A Europe-wide study reported significant variability in the incidence of prenatal anxiety across countries and regions, ranging from 7.7\u0026ndash;36.5%, indicating that pregnancy-related anxiety is a critical issue that warrants attention (Val \u0026amp; Miguez, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The ramifications of pregnancy anxiety extend to physical health, leading to complications such as pregnancy hypertension and mental disorders like prenatal and postnatal depression. These mental disorders can negatively affect maternal-fetal attachment and contribute to adverse neurodevelopmental, cognitive and behavioral outcomes in children, including low birth weight and preterm birth, which increase neonatal morbidity and mortality (Mikolajkow \u0026amp; Malyszczak, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Shapiro et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnxiety during pregnancy is distinct from generalized anxiety disorder and depression, often not meeting the criteria for anxiety disorders (Brunton et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sinesi et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Kulshreshtha et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that adverse pregnancy history differentially affects various types of anxiety. Pregnant women with unfavorable pregnancy experience are substantially more likely to experience pregnancy-specific anxiety, while general anxiety remains unaffected. Pregnant-related anxiety and depression symptoms are marginally linked with the impact of previous perinatal loss (Armstrong, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Shapiro et al. (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) approaches from the perspective of pregnancy, found that different types of adverse pregnancy history relate differently to pregnant-related anxiety at various pregnancy stages. Specifically, prior elective abortion was significantly associated with higher pregnancy anxiety scores in the first and second trimesters, and this trend continued into the third trimester (Shapiro et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The contribution of general anxiety and depression to the variance in pregnancy-related anxiety scores was minimal (Brunton et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). International studies have further emphasized anxiety as one of the core risk factors for antenatal depression. A study in Australia identified antenatal depression, antenatal anxiety, major life events, low social support, and a history of depression as significant predictors of postnatal depression, with antenatal depression and anxiety being among the strongest predictors (Milgrom et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Additionally, antenatal anxiety has been linked to postpartum suicidal ideation (SI), a precursor to suicide attempts among new mothers (Schafer et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This association highlights the critical need to address prenatal anxiety to prevent severe postpartum mental health complications.\u003c/p\u003e \u003cp\u003eThis study aims to investigate the subjective perception of stress and pregnancy-related anxiety among pregnant women and explore their relationship with adverse pregnancy experience and depression, hypothesized a significant mediating effect between them. Currently, there is a lack of research exploring the interplay between adverse pregnancy experience, perceived stress, and pregnancy-related anxiety. Therefore, this study seeks to elucidate these relationships and their implications for the mental health of pregnant women and provide basis for developing clinical therapies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe mental health status of pregnant women is routinely assessed as a part of antenatal care visits. Since 2021, we set up a mental health surveillance system for pregnant women during pregnancy. Pregnant women were asked to scan a QR code and self-report their mental health status via mobile phone. To investigate mental health status in early pregnancy (gestational age\u0026thinsp;\u0026lt;\u0026thinsp;14 weeks), we included all pregnant women who attended antenatal visits at the maternity and infant health hospital in Shanghai from July 5, 2021, to December 27, 2021. The following cases were excluded: (1) more than 20% missing items in any survey scale, (2) incorrectly filled scales, (3) filled wrong identity number, (4) repeatedly submitted. After applying these exclusion criteria, 2307 pregnant women remained. This study was approved by the Institutional Review Board of Changning Maternity \u0026amp; Infant Health Hospital (CNFBLLKT-2023-018), and the process met the medical standards.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePregnancy-Related Anxiety Questionnaire (PrAQ)\u003c/h2\u003e \u003cp\u003ePregnancy-related anxiety is a 13-item instrument designed to assess anxiety specifically related to pregnancy (Brunton et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The questionnaire evaluates three key areas: self-concern, worry about fetal health, and worry about childbirth. Each item is rated on a 4-point scale (0\u0026thinsp;=\u0026thinsp;no worry, 1\u0026thinsp;=\u0026thinsp;occasionally worried, 3\u0026thinsp;=\u0026thinsp;often worried, 4\u0026thinsp;=\u0026thinsp;always worried), with a total possible score of 52. Higher scores indicate higher levels of pregnancy-related anxiety. A total score\u0026thinsp;\u0026ge;\u0026thinsp;24 is considered the cut-off for identifying significant anxiety. This scale has been translated into many languages and utilized in various countries and regions, consistently demonstrating good reliability and validity (Hadfield et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022a\u003c/span\u003e). The reliability, measured by Cronbach\u0026rsquo;s alpha, typically ranges from 0.70 to 0.85 (Mudra et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Mudra et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) also demonstrated PrAQ-13 has strong construct validity, and effectively differentiates pregnancy-related anxiety from general anxiety, further supporting its discriminant validity. In this study, the Cronbach\u0026rsquo;s alpha for this scale was 0.824.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEdinburgh Post Natal Depression Scale (EPDS)\u003c/h3\u003e\n\u003cp\u003eThe Edinburgh Post Natal Depression Scale (EPDS) is a widely utilized and well-validated screening tool for detecting depressive symptoms in pregnant women worldwide (Cox et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1987\u003c/span\u003e; Gemmill et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). It exhibits a sensitivity of 65\u0026ndash;100% and specificity of 49\u0026ndash;100% (Eberhard-Gran et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Research indicated that the EPDS is effective not only for postpartum depression but also for antenatal depression (Kozinszky \u0026amp; Dudas, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). A cut-off score of 13 was employed, with score\u0026thinsp;\u0026ge;\u0026thinsp;13 indicating probable depression (Matthey et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), The EPDS has been validated across diverse cultures and has demonstrated superiority to unstructured health professional assessment or routine care (Levis et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Studies consistently report high internal consistency, with Cronbach\u0026rsquo;s alpha values typically ranging from 0.80 to 0.87, indicating good reliability (Shrestha et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In this study, the Cronbach\u0026rsquo;s alpha for this scale was 0.710.\u003c/p\u003e\n\u003ch3\u003ePerceived stress status (PSS-14)\u003c/h3\u003e\n\u003cp\u003ePerceived stress status was assessed using the Chinese version of PSS-14, which consists of seven positive and seven negative items, and has been validated in Chinese medical residents and community residents (Huang et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Shi et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The PSS-14 measures whether respondents perceive their lives as unpredictable, uncontrollable, or overloaded (Cohen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). Each item is rated on a 5-point scale from 0 (never) to 4 (very often). PSS scores are obtained by reversing the scores on the seven positive items (items 4, 5, 6, 7, 9, 10, and 13) and summing across all items. Higher scores indicate greater stress levels and a higher likelihood that environmental demands exceed an individual\u0026rsquo;s coping ability. The PSS-14 has strong internal consistency (α\u0026thinsp;=\u0026thinsp;0.84 to 0.86) and good test-retest reliability (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.85 over a 2-day period, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.55 over a 6-week period; Cohen et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). In this study, the Cronbach\u0026rsquo;s alpha for this scale was 0.713.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics 28.0. Descriptive statistics, independent sample \u003cem\u003et\u003c/em\u003e-tests, and correlation tests were conducted. Median analyses were performed using the PROCESS macro (version 4.1 by Andrew F. Hayes) for SPSS with 5000 bootstrap samples.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDescription of demographic information\u003c/h2\u003e \u003cp\u003eDemographic information and group differences for perceived stress (PSS), Pregnancy-related anxiety (PrAQ), and Edinburgh Postnatal Depression Scale (EPDS) among the pregnant women are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The demographic variables include age, education, employment status, Body Mass Index (BMI), and four stressful pregnancy-related incidents: history of induced abortion, medical abortion, induced labor, and premature labor. These incidents were aggregated into a composite variable, \u0026ldquo;adverse pregnancy experience\u0026rdquo;, which indicates whether a pregnant woman has experienced any negative pregnancy experience. The average age of the participants is 31.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64 years, with 21.8% classified as elderly pregnant women (age\u0026thinsp;\u0026ge;\u0026thinsp;35). 32% of pregnant women are unhealthy on the BMI scale, and 32% of mothers had a negative pregnancy experience. The chi-square test identified significant differences in formation between groups with high and low education levels, as well as between those with and without advanced maternal age. These findings are clinically meaningful and warrant further discussion.\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\u003eDemographic information for the pregnant women (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2307)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal \u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrAQ\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\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\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1803(78.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.99**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.84\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e504(21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.37\u0026thinsp;\u0026plusmn;\u0026thinsp;6.73**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e19.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e38.83\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e27.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.93**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e11.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle school and high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161(7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e36.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e21.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.58\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1673(72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.21\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.55\u0026thinsp;\u0026plusmn;\u0026thinsp;4.41**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate school and higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e455(19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e30.18\u0026thinsp;\u0026plusmn;\u0026thinsp;6.52**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2136(92.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.01\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e33.09\u0026thinsp;\u0026plusmn;\u0026thinsp;7.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (18.5\u0026thinsp;\u0026le;\u0026thinsp;BMI\u0026thinsp;\u0026lt;\u0026thinsp;24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1799(78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.97\u0026thinsp;\u0026plusmn;\u0026thinsp;6.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.84\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e214(9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e33.47\u0026thinsp;\u0026plusmn;\u0026thinsp;6.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e21.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverweight (25\u0026thinsp;\u0026le;\u0026thinsp;BMI\u0026thinsp;\u0026lt;\u0026thinsp;29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e272(11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.90\u0026thinsp;\u0026plusmn;\u0026thinsp;6.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e30.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e19.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduced abortion history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1985(86.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.07\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.74\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.91\u0026thinsp;\u0026plusmn;\u0026thinsp;4.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e322(14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.26\u0026thinsp;\u0026plusmn;\u0026thinsp;7.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e19.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical abortion history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1838(79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.84\u0026thinsp;\u0026plusmn;\u0026thinsp;6.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e469(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e33.09\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduced labor history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2263(98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44(1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e33.80\u0026thinsp;\u0026plusmn;\u0026thinsp;7.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremature labor history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2284(99.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.89\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e35.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e21.13\u0026thinsp;\u0026plusmn;\u0026thinsp;4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal negative pregnancy experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1567(67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e740(32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e20.41\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.17\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations among continuous variables\u003c/h2\u003e \u003cp\u003eThe Pearson\u0026rsquo;s correlation analysis results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Perceived stress was significantly correlated with negative pregnancy experiences (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), pregnancy-related anxiety (r= -0.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and depression symptoms (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0,05). Pregnancy-related anxiety was significantly positively correlated with perceived stress (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and antenatal depression symptoms (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.50, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, antenatal depression was significantly correlated with perceived stress (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.60, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\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\u003eCorrelations among negative pregnancy experience, PSS, PrAQ, and EPDS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative pregnancy experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrAQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative pregnancy experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.05\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e*\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e32.09\u0026thinsp;\u0026plusmn;\u0026thinsp;6.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.60**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrAQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.50**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.90\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.60**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMediating effects and moderating effects\u003c/h2\u003e \u003cp\u003eThe direct relationship between APE and depression was significant by regression analysis with a coefficient of 0.05 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The direct path (c') between adverse pregnancy experience and EPDS was not significant, with a coefficient of 0.12 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the indirect paths were all significant. The indirect path from adverse pregnancy experience to EPDS via PSS (path a\u003csub\u003e1\u003c/sub\u003e*b\u003csub\u003e1\u003c/sub\u003e, a\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.66, b1\u0026thinsp;=\u0026thinsp;0.29, 95% CI = [0.09, 0.29]) indicated a significant mediating role of perceived stress. Similarly, the indirect path from adverse pregnancy experience to EPDS through PrAQ (path a\u003csub\u003e2\u003c/sub\u003e*b\u003csub\u003e2\u003c/sub\u003e, a\u003csub\u003e2\u003c/sub\u003e=-0.42, b\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.27, 95% CI = [-0.17, -0.06]) indicated a significant mediating role of pregnancy-related anxiety. Interestingly, the coefficients for the first half of this path (a\u003csub\u003e2\u003c/sub\u003e) were positive, whereas the second half of the coefficients (b\u003csub\u003e2\u003c/sub\u003e) were negative, suggesting a masking effect that warrants further discussion. Additionally, the third indirect path involving both PSS and PrAQ as mediator between adverse pregnancy experience and EPDS (a\u003csub\u003e1\u003c/sub\u003e*d\u003csub\u003e21\u003c/sub\u003e*b\u003csub\u003e2\u003c/sub\u003e, a\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.66, d\u003csub\u003e21\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.30, b\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.27, 95% CI = [0.02, 0.08]) was significant. This means that both perceived stress and pregnancy-related anxiety mediated the relationship between adverse pregnancy experiences and depression. The mediating model is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003cp\u003eWe also identified a significant moderating effect of BMI on the relationship between adverse pregnancy experiences and depression (\u003cem\u003eR\u003c/em\u003e\u0026sup2; = 0.01, \u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This indicates that the impact of adverse pregnancy experiences on depression varies depending on an individual\u0026rsquo;s BMI. Specifically, different BMI levels may either amplify or attenuate the risk of depression in response to these experiences. The moderating effect of BMI is presented separately in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDeclining birth rates have prompted many countries to implement policies that actively promote fertility. However, numerous women opt not to have children, driven by various factors. Research highlights that psychological stress and trauma stemming from adverse pregnancy experiences are among the primary contributors to this decision (Li et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This study investigates the mental health of women who have encountered negative pregnancy experiences, with the goal of enhancing their well-being by exploring the associations between such experiences, perceived stress, anxiety, and depression, which may, in turn, influence their reproductive intentions.\u003c/p\u003e \u003cp\u003eThe findings of this study support the proposed hypothesis and are consistent with previous research, demonstrating that adverse pregnancy experiences are linked to depression in women within the first 14 weeks of gestation. This association is mediated by perceived stress and pregnancy-related anxiety.\u003c/p\u003e \u003cp\u003eBy analyzing and comparing the demographic data presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it is evident that education level, age, and adverse pregnancy experiences significantly influence perceived stress, anxiety, and depression among antenatal women. Notably, while differences in mental health across various BMI subgroups were not statistically significant, our findings revealed that BMI significantly moderates the impact of adverse pregnancy experiences on depression. This indicates that BMI levels do not directly affect the mental health of pregnant women; rather, the influence of adverse pregnancy experiences on depression is contingent upon individual BMI levels. Among pregnant women who did not experience a negative pregnancy event, healthy BMI pregnant women had more depression, but among pregnant women who experienced a negative pregnancy event, pregnant women with unhealthy BMI values had higher levels of depression. Specifically, variations in BMI may alter the magnitude or direction of the risk posed by adverse pregnancy experiences on depression, underscoring BMI\u0026rsquo;s critical moderating role in this mental health process.\u003c/p\u003e \u003cp\u003eThe correlation analysis results presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e reveal that adverse pregnancy events are significantly correlated with perceived stress, pregnancy-related anxiety, and depression, though the correlation coefficients are relatively low. However, the mediating coefficient is significant and relatively robust. Previous research has indicated similar issue that this represents a distinct type of mediating variable, capable of establishing an indirect connection between two variables that would otherwise exhibit no apparent relationship (Xin, \u0026amp; Chi, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). In this context, it can be interpreted as follows: the predictive effect of negative pregnancy events on depression is nearly negligible. However, through the mediating roles of perceived stress and pregnancy-related anxiety, an indirect influence can emerge. Meanwhile, perceived stress, pregnancy-related anxiety, and depression exhibit strong intercorrelations, with high correlation coefficients, indicating a significant positive relationship among these three variables. This suggests that these psychological factors are closely related and may influence each other in meaningful ways within the context of pregnancy.\u003c/p\u003e \u003cp\u003eIn the mediation model, the direct effect of negative pregnancy experiences on depression was not statistically significant, while the total effect and all three mediating pathways showed significant results. This suggests that depressive symptoms during pregnancy should be considered from a multidimensional perspective. Specifically, adverse pregnancy experiences do not directly cause antenatal depression. Instead, these experiences contribute to depressive symptoms indirectly, primarily through increased perceived stress and pregnancy-related anxiety. This highlights the importance of addressing both stress and anxiety in pregnant women as key mediators in the relationship between negative pregnancy experiences and the development of depression. By considering these mediating factors, interventions can be more effectively targeted to reduce the risk of antenatal depression.\u003c/p\u003e \u003cp\u003eConsistent with previous research, pregnant women\u0026rsquo;s perceived stress significantly moderates depression induced by adverse pregnancy experiences in this study. After experiencing a negative pregnancy event, pregnant women face stress from a variety of sources, such as moral condemnation, relationship changes, physical pain, family conflicts, and psychological changes, etc. (Traylor et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These perceived stressors can significantly contribute to depression in subsequent pregnancies. Therefore, psychological counselors dealing with pregnant women who have had negative pregnancy experiences should inquire about these negative experiences to explore and alleviate the sources of stress, potentially leading to better outcomes.\u003c/p\u003e \u003cp\u003eContrary to previous perceptions, our study revealed a negative correlation between negative pregnancy experiences and pregnancy-related anxiety at path a\u003csub\u003e2\u003c/sub\u003e, while path b\u003csub\u003e2\u003c/sub\u003e exhibit a positive correlation. This pattern suggests the presence of a masking effect in mediation. While negative pregnancy experiences might initially seem to reduce anxiety (possibly due to denial or a protective cognitive mechanism), they ultimately contribute to increased anxiety through other pathways. It seems like women with negative pregnancy experiences are less sensitive to the three factors of the Pregnancy-Related Anxiety Scale: concern for self, concern for the health of the fetus, and concern for childbirth. But the masking effect indicates that the true relationship between adverse pregnancy experiences and pregnancy-related anxiety may be more complex than previously understood. This finding underscores the importance of considering the intricate interplay between various psychological factors when assessing the impact of negative pregnancy experiences on mental health outcomes.\u003c/p\u003e \u003cp\u003eThis study has significant highlights. First, the data were collected directly from real-world clinical settings, ensuring that participants were engaged and provided responses that closely reflect actual conditions, thereby enhancing the ecological validity and accuracy of the findings. Second, the study\u0026rsquo;s robustness is supported by a substantial sample size, comprising 2,307 women over a period exceeding six months, which strengthens the reliability and generalizability of the results. Third, in contrast to existing research, this study extends its focus to the clinical applicability of the findings, emphasizing the importance of addressing stress sources and sensitivities among pregnant women with adverse pregnancy experiences. However, the study has certain limitations. As a cross-sectional design, it does not include longitudinal data tracking these women throughout the antenatal and postpartum periods, thus limiting causal inferences. Furthermore, the practical relevance of the proposed implications warrants further validation in additional clinical settings to assess their broader applicability.\u003c/p\u003e \u003cp\u003eIn conclusion, this study offers valuable insights into the mental health of pregnant women who have experienced adverse pregnancy events, as well as the underlying mechanisms that may impact their psychological well-being. It emphasizes the importance of addressing perceived stress and pregnancy-related anxiety to mitigate depression and enhance overall well-being.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNo potential conflict of interest was reported by the author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Changning Maternity \u0026amp; Infant Health Hospital (CNFBLLKT-2023-018), and the procedures adhered to medical standards. All participants signed consent forms to participate in the study, and they were informed of their right to withdraw at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have reviewed the manuscript and given their consent for its publication in \u003cem\u003eBMC Pregnancy and Childbirth\u003c/em\u003e. Each author has contributed significantly to the work and is accountable for the content of the article. Furthermore, the authors affirm that the content has not been previously published and is not under consideration for publication elsewhere.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the STI 2030- Major Projects (Grant Number: 2021ZD0200500), East China Normal University Medicine and Health Joint Fund (2022JKXYD05001), Shanghai Dingbo-ECNU Project (Grant Number: DBYL-2022-HS), and Science and Technology Commission of Changning District, Shanghai (CNKW2022Y36).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZiqi Guan wrote the main manuscript text and conducted the data analysis. Jun Li, Dan Ji, and Yanan Huang collected data and did administrative stuff. Zherui Lin, and Leyi Zhang did literature review and wrote manuscript text. Juzhe Xi and Wenli Fang designed the research and did administrative stuff. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trail\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdler JM, Wagner JW, McAdams DP. Personality and the coherence of psychotherapy narratives [Article]. J Res Pers. 2007;41(6):1179\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jrp.2007.02.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jrp.2007.02.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmstrong DS. Impact of prior perinatal loss on subsequent pregnancies [Article]. Jognn-Journal Obstetric Gynecologic Neonatal Nurs. 2004;33(6):765\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0884217504270714\u003c/span\u003e\u003cspan address=\"10.1177/0884217504270714\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayrampour H, Vinturache A, Hetherington E, Lorenzetti DL, Tough S. Risk factors for antenatal anxiety: A systematic review of the literature [Review]. J Reproductive Infant Psychol. 2018;36(5):476\u0026ndash;503. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02646838.2018.1492097\u003c/span\u003e\u003cspan address=\"10.1080/02646838.2018.1492097\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBearak J, Popinchalk A, Ganatra B, Moller A-B, Tuncalp O, Beavin C, Kwok L, Alkema L. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990\u0026ndash;2019 [Article]. Lancet Global Health. 2020;8(9):E1152\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s2214-109x(20)30315-6\u003c/span\u003e\u003cspan address=\"10.1016/s2214-109x(20)30315-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck CT. Predictors of postpartum depression: an update. Nurs Res. 2001;50(5):275\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunton R, Dryer R, Saliba A, Kohlhoff J. Re-examining pregnancy-related anxiety: A replication study [Article]. Women Birth. 2019;32(1):E131\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.wombi.2018.04.013\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2018.04.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunton RJ, Dryer R, Saliba A, Kohlhoff J. Pregnancy anxiety: A systematic review of current scales [Review]. J Affect Disord. 2015;176:24\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2015.01.039\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2015.01.039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunton RJ, Dryer R, Saliba A, Kohlhoff J. The initial development of the Pregnancy-related Anxiety Scale. Women Birth. 2019;32(1):e118\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen S, Kamarck T, Mermelstein R. (1983). A global measure of perceived stress. J Health Soc Behav, 385\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCote-Arsenault D, Mahlangu N. (1999). Impact of perinatal loss on the subsequent pregnancy and self: women's experiences. \u003cem\u003eJournal of obstetric, gynecologic, and neonatal nursing: JOGNN\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 274\u0026ndash;282. ://MEDLINE:10363539.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCouto ER, Couto E, Vian B, Gregorio Z, Nomura ML, Zaccaria R, Passini Junior R. Quality of life, depression and anxiety among pregnant women with previous adverse pregnancy outcomes [Article]. Sao Paulo Med J. 2009;127(4):185\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/s1516-31802009000400002\u003c/span\u003e\u003cspan address=\"10.1590/s1516-31802009000400002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J psychiatry. 1987;150(6):782\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen O, S. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta psychiatrica Scandinavica. 2001;104(4):243\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEleje GU, Oguejiofor CB, Oriji SO, Ekwuazi KE, Ugwu EO, Igbodike EP, Malachy DE, Nwankwo EU, Onah CE, Ugboaja JO, Ikechebelu JI, Nwagha UI. Depression, anxiety, and stress and adverse pregnancy outcomes in pregnant women with history of recurrent pregnancy loss in Nigeria [Article]. Int J Psychiatry Med. 2024;59(3):303\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/00912174231199215\u003c/span\u003e\u003cspan address=\"10.1177/00912174231199215\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, Al-Memar M, Tapp S, Van Calster B, Wynants L, Timmerman D, Bourne T. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study [Article]. Am J Obstet Gynecol. 2020;222(4):1\u0026ndash;e22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajog.2019.10.102\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2019.10.102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Article 367.e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaudet C. Pregnancy after perinatal loss: association of grief, anxiety and attachment [Article]. J Reproductive Infant Psychol. 2010;28(3):240\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02646830903487342\u003c/span\u003e\u003cspan address=\"10.1080/02646830903487342\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Article Pii 922430955.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGemmill AW, Leigh B, Ericksen J, Milgrom J. A survey of the clinical acceptability of screening for postnatal depression in depressed and non-depressed women. BMC Public Health. 2006;6:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGong X, Hao J, Tao F, Zhang J, Wang H, Xu R. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study [Article]. Eur J Obstet Gynecol Reproductive Biology. 2013;166(1):30\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejogrb.2012.09.024\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2012.09.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHadfield K, Akyirem S, Sartori L, Abdul-Latif A-M, Akaateba D, Bayrampour H, Daly A, Hadfield K, Abiiro GA. Measurement of pregnancy-related anxiety worldwide: a systematic review. BMC Pregnancy Childbirth. 2022a;22(1):331.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHadfield K, Akyirem S, Sartori L, Abdul-Latif A-M, Akaateba D, Bayrampour H, Daly A, Hadfield K, Abiiro GA. Measurement of pregnancy-related anxiety worldwide: a systematic review [Review]. BMC Pregnancy Childbirth. 2022b;22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eArticle 331. https://doi.org/10.1186/s12884-022-04661-8\u003c/span\u003e\u003cspan address=\"Article 331. 10.1186/s12884-022-04661-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamama L, Rauch SAM, Sperlich M, Defever E, Seng JS, SPONTANEOUS OR ELECTIVE ABORTION AND RISK FOR POSTTRAUMATIC STRESS AND DEPRESSION DURING SUBSEQUENT PREGNANCY [Article]. Depress Anxiety. 2010;27(8):699\u0026ndash;707. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/da.20714\u003c/span\u003e\u003cspan address=\"10.1002/da.20714\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PREVIOUS EXPERIENCE OF.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerbert D, Young K, Pietrusinska M, MacBeth A. The mental health impact of perinatal loss: A systematic review and meta-analysis [Review]. J Affect Disord. 2022;297:118\u0026ndash;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2021.10.026\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2021.10.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoriuchi S, Tsuda A, Yoneda K, Aoki S. Mediating effects of perceived stress on the relationship of positivity with negative and positive affect [Article]. Psychol Res Behav Manage. 2018;11:299\u0026ndash;303. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/prbm.S164761\u003c/span\u003e\u003cspan address=\"10.2147/prbm.S164761\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang F, Wang H, Wang Z, Zhang J, Du W, Su C, Jia X, Ouyang Y, Wang Y, Li L. Psychometric properties of the perceived stress scale in a community sample of Chinese. BMC Psychiatry. 2020;20:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunter A, Tussis L, MacBeth A. The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis [Review]. J Affect Disord. 2017;223:153\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2017.07.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2017.07.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKozinszky Z, Dudas RB. Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period. J Affect Disord. 2015;176:95\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulshreshtha S, Siwatch S, Aggarwal N, Rohilla M, Grover S. Mental health issues in antenatal women with prior adverse pregnancy outcomes: Unmasking the mental anguish of rainbow pregnancy [Article]. Indian J Med Res. 2023;158(2):190\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/ijmr.ijmr_1241_21\u003c/span\u003e\u003cspan address=\"10.4103/ijmr.ijmr_1241_21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry. 2008;8:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. (2020). Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. \u003cem\u003ebmj\u003c/em\u003e, \u003cem\u003e371\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Q, Yang R, Zhou Z, Qian W, Zhang J, Wu Z, Jin L, Wu X, Zhang C, Zheng B. Fertility history and intentions of married women, China. Bull World Health Organ. 2024;102(4):244.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcinko VM, Marcinko D, Dordevic V, Oreskovic S. Anxiety and Depression in Pregnant Women with Previous History of Spontaneous Abortion [Article]. Coll Antropol. 2011;35:225\u0026ndash;8. ://WOS:000289956500036.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin CR, Martin CJH. Screening for antenatal depression (AND) using self-report questionnaires: Conceptual issues and measurement limitations. The Neuroscience of Depression. Elsevier; 2021. pp. 195\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale\u0026ndash;implications for clinical and research practice. Arch Women Ment Health. 2006;9:309\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarthy FP, Moss-Morris R, Khashan AS, North RA, Baker PN, Dekker G, Poston L, McCowan LME, Walker JJ, Kenny LC, O'Donoghue K. Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. Bjog-an Int J Obstet Gynecol. 2015;122(13):1757\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1471-0528.13233\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.13233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendes DCG, Fonseca A, Cameirao MS. The relationship between healthcare satisfaction after miscarriage and perinatal grief symptoms: A cross-sectional study on Portugal residents [Article]. Soc Sci Med. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2024.117037\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2024.117037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e., 353, Article 117037.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026iacute;guez MC, V\u0026aacute;zquez MB. Risk factors for antenatal depression: A review. World J Psychiatry. 2021;11(7):325.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikolajkow A, Malyszczak K. Biological factors and consequences of pregnancy-related anxiety - What do we know so far? [Article]. Psychiatr Pol. 2022;56(6):1289\u0026ndash;314. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12740/pp/144138\u003c/span\u003e\u003cspan address=\"10.12740/pp/144138\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J, Ericksen J, Ellwood D, Buist A. Antenatal risk factors for postnatal depression: A large prospective study [Article]. J Affect Disord. 2008;108(1\u0026ndash;2):147\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2007.10.014\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2007.10.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMudra S, G\u0026ouml;bel A, Barthel D, Hecher K, Schulte-Markwort M, Goletzke J, Arck P, Diemert A. Psychometric properties of the German version of the pregnancy-related anxiety questionnaire-revised 2 (PRAQ-R2) in the third trimester of pregnancy. BMC Pregnancy Childbirth. 2019;19:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray D, Cox JL. Screening for depression during pregnancy with the Edinburgh Depression Scale (EDDS). J reproductive infant Psychol. 1990;8(2):99\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsman NN, Bahri AI. Impact of Altered Hormonal and Neurochemical Levels on Depression Symptoms in Women During Pregnancy and Postpartum Period [Article]. J Biochem Technol. 2019;10(1):16\u0026ndash;23. ://WOS:000466173600004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, Brosens JJ, Brewin J, Ramhorst R, Lucas ES, McCoy RC, Anderson R, Daher S, Regan L, Al-Memar M, Bourne T, MacIntyre DA, Rai R, Christiansen OB, Coomarasamy A. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss [Review]. Lancet. 2021;397(10285):1658\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0140-6736(21)00682-6\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(21)00682-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchafer KM, Mulligan E, Shapiro MO, Flynn H, Joiner T, Hajcak G. Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation. Anxiety Stress Coping. 2024;1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10615806.2024.2333377\u003c/span\u003e\u003cspan address=\"10.1080/10615806.2024.2333377\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro GD, Fraser WD, Frasch MG, Seguin JR. Psychosocial stress in pregnancy and preterm birth: associations and mechanisms [Review]. J Perinat Med. 2013;41(6):631\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1515/jpm-2012-0295\u003c/span\u003e\u003cspan address=\"10.1515/jpm-2012-0295\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro GD, Seguin JR, Muckle G, Monnier P, Fraser WD. Previous pregnancy outcomes and subsequent pregnancy anxiety in a Quebec prospective cohort [Article]. J Psychosom Obstet Gynecol. 2017;38(2):121\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0167482x.2016.1271979\u003c/span\u003e\u003cspan address=\"10.1080/0167482x.2016.1271979\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi C, Guo Y, Ma H, Zhang M. Psychometric validation of the 14-item perceived stress scale in Chinese medical residents. Curr Psychol. 2019;38:1428\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShrestha SD, Pradhan R, Tran TD, Gualano RC, Fisher JR. Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2016;16:1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinesi A, Maxwell M, O'Carroll R, Cheyne H. Anxiety scales used in pregnancy: systematic review [Review]. Bjpsych Open. 2019;5(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/bjo.2018.75\u003c/span\u003e\u003cspan address=\"10.1192/bjo.2018.75\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Article e5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThongsonnboon W, Kaewkiattikun K, Kerdcharoen N. Perceived Stress and Associated Factors Among Pregnant Women Attending Antenatal Care in Urban Thailand [Article]. Psychol Res Behav Manage. 2020;13:1115\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/prbm.S290196\u003c/span\u003e\u003cspan address=\"10.2147/prbm.S290196\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTraylor CS, Johnson JD, Kimmel MC, Manuck TA. Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. Am J Obstet Gynecol MFM. 2020;2(4):100229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVal A, Miguez MC. Prevalence of Antenatal Anxiety in European Women: A Literature Review [Review]. Int J Environ Res Public Health. 2023;20(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eArticle 1098. https://doi.org/10.3390/ijerph20021098\u003c/span\u003e\u003cspan address=\"Article 1098. 10.3390/ijerph20021098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan P, Gay CL, Lee KA. Prior pregnancy loss and sleep experience during subsequent pregnancy [Article]. Sleep Health. 2023;9(1):33\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sleh.2022.11.004\u003c/span\u003e\u003cspan address=\"10.1016/j.sleh.2022.11.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXin Z, Chi L. The relationship between family functioning and children's loneliness: the role of mediators. Acta Physiol Sinica. 2003;35(2):216\u0026ndash;21. (Chinese version).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYilmaz SD, Beji NK. Effects of perinatal loss on current pregnancy in Turkey [Article]. Midwifery. 2013;29(11):1272\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.midw.2012.11.015\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2012.11.015\" 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":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"adverse pregnancy experience, depression, stress, pregnancy-related anxiety, mediating effect","lastPublishedDoi":"10.21203/rs.3.rs-5323351/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5323351/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWomen experience a range of challenging emotions during pregnancy, such as anxiety and depression, especially for the woman with a history of adverse pregnant experience. This study investigates the mental health impact of negative pregnancy experiences on antenatal women, focusing on the relationships between negative pregnancy events, perceived stress, pregnancy-related anxiety, and depression.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 2,307 pregnant women participated in this cross-sectional study. Data were collected from hospital outpatient obstetrics and gynecology clinics by online questionnaires.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePerceived stress and pregnancy-related anxiety served as mediators linking otherwise weakly correlated negative pregnant experiences and antenatal depression. Significant differences in BMI were observed across subgroups, moderating the impact of negative pregnancy events on depression.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings underscore the mediating effects of perceived stress, and pregnancy-related anxiety in the relationship of negative pregnant experiences and antenatal depression. Interventions should address multiple perspectives, focusing on alleviating stress and anxiety to improve the mental health and reproductive willingness of women with adverse pregnancy experiences\u003c/p\u003e","manuscriptTitle":"Adverse Pregnancy Experiences and Antenatal Depression: Mediation by Stress and Anxiety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 12:13:49","doi":"10.21203/rs.3.rs-5323351/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af41ecd8-804c-4376-8f8d-b06cd26a540e","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-06T04:39:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-06 12:13:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5323351","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5323351","identity":"rs-5323351","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}