In this study we found that some sociopsychological factors such as education status, self-esteem and resilience were associated with coping styles during pregnancy, which were also strongly associated with postpartum depression and provided further evidence to support the implementation of coping interventions during pregnancy for postpartum depression prevention.
Women with a higher educational level scored higher on both positive and negative coping. A study in Ethiopia had similar findings: compared with women without formal education, those with formal education had higher scores both in problem-and emotion-focused coping[20]. The association of better educational background with higher levels of positive coping might be attributed to women’s access to resources. Women with lower educational levels were more likely to perceive greater stress[37],which would affect the way they respond to stressors, and weaken their abilities dealing with challenges. Interestingly,we did not hypothesize that negative coping is positively associated with education status, though dummy 2 only showed marginal statistical significance. One possibility is that coping process is dynamic, and may change in response to different situations[11, 12, 38]. For instance, women who actively solve problems when facing particular stressors might also employ avoidant strategies in other situations. In our investigation, participants only were asked to answer how they cope with stress generally during pregnancy rather than to report their efforts to resolve pregnancy-specific stressors. When women were filling in the questionnaires,different women may have reflected on different types of stressor. Lazarus described how problem-solving and emotion-focused coping should not be conceptualized as independent of one another, or competing, and instead should be viewed as complementary functions working in tandem.[39] Given that negative coping is not always 'negative' and the specific coping strategies are various, further studies should explore the integration of different coping behaviors that might facilitate the ability to handle pregnancy-and childbirth-related stressors, rather than one particular coping strategy and its consequent effects on mental health. This could identify combinations of coping strategies that could withstand stressors surrounding pregnancy. This suggests that individuals adapting better to stressful events might be exactly those who could combine different coping strategies effectively.
Women with better resilience were more likely to have a higher level of positive coping and lower level of negative coping in our study. Resilience refers to the ability to bounce back and recover from stress, or to continue forward when facing adversities[31]. Resilient individuals can continue functioning when confronting stressors, which may be explained by their ‘resilience resources’, including optimism, self-efficacy or mastery, emotional intelligence, and close social networks [40, 41]. Women exposed to stressful pregnancy-related events are likely to cope better if they have resilience resources, and the more the better[40]. Few studies have been undertaken which explore the relationship between resilience and coping during pregnancy, with the exception of those focused on specific resilience resources in pregnancy. Existing research suggests that that optimism and self-efficacy are positively related with avoidant coping, and negatively related with active coping[42, 43], which is consistent with our findings that women with better resilience scored higher on positive coping while scored lower on negative coping. In another study, higher self-esteem was associated with increased use of positive coping, which could be attributed to the fact that high self-esteem, as positive self-evaluation, could be seen as one of the resources of coping and can be used to confront stressors[44]. Others have also shown that women who view themselves positively are better able to adapt to their new role as a mother than women with low self-esteem [44, 45]. Our results concur with a qualitative interview study undertaken with HIV-positive pregnant women in South Africa, which concluded that the increased use of active coping was associated with higher self-esteem and social supports[18]. This suggests that it would be necessary to identify women antenatally with these factors and help them deal with stressors during pregnancy better for care providers.
Our findings indicate that women with lower level of positive coping and higher level of negative coping in the antenatal period are likely to be more vulnerable to experiencing postpartum depression. This aligns with previous research that deemed postpartum depression was negatively correlated with positive coping and positively correlated with negative coping style[46-48][24-27]. For specific coping strategies, two longitudinal studies have shown the occurrence of postpartum depression is associated with avoidant coping behaviours in pregnancy, which were similar in characterization with negative coping[49, 50]. According to stress and coping theory, coping may play a critical role in mediating the influence of pregnancy-related stressors[51]. Coping with stressors positively means mobilizing internal forces or resorting to external resources to minimize the adverse effects caused by stressors. Conversely, women adopting negative coping such as avoidance and substance abuse might be vulnerable to prenatal stress exposures, which is not conducive to the solution of the problem but promotes the generation of negative emotion[21]. Coping intervention could be targeted for women with coping issues to prevent postpartum depression for care providers.
There are a number of limitations in this research. Firstly, 45.38% of participants were lost to follow up during the study, potentially impacting on both internal and external validity. However, baseline characteristics between study sample and the participants lost-to-follow-up were similar, suggesting that our sample was representative of the population of women attending the hospital. A further limitation is that most participants in our research were from urban contexts, and it is not clear how they apply in more rural communities. Finally, all participants were recruited by convenience sampling, suggesting that participants in our study might be atypical and generalizing our finding should be cautious.