Perinatal loss is the most common failure of procreation with estimated up to 25% [1, 2]. Perinatal loss women, experienced the loss of a baby or fetus, often suffer a traumatic experience with serious psychological consequences like post-traumatic stress reactions or even post-traumatic stress disorder (PTSD) [1, 3]. In fact, post-traumatic stress reactions were known to have serious negative implications for women, offspring, families and society [4–6]. Several studies have found the single effect of perinatal grief, perinatal depression and anxiety, and social support on post-traumatic stress reactions [7–9]. However, there are few studies that have analyzed these variables in the same model or theoretical framework, and then studied their interacting effect on post-traumatic stress reactions among perinatal loss women. Therefore, it is essential to analyse key intermediary or moderating factors resulting in post-traumatic stress reactions among perinatal loss women, so as to take effective preventive intervention to decrease psychological disorders among perinatal loss women.
Perinatal grief is the common emotional reactions for women to experience perinatal loss [10]. Perinatal grief may lead to a range of physical, psychosocial, emotional, and cognitive changes [11]. Women who experienced higher levels of perinatal grief were more likely to report feelings of unfairness, guilt, and loss of control [12]. These intense emotions can disrupt an individual's perception of the world and their fundamental beliefs, thereby perpetuating the trauma and contributing to the development of post-traumatic stress reactions [13]. Additionally, Heazell et al.'s study argued that women who experience higher levels of perinatal grief, may report more intrusive thoughts, images, and nightmares related to the loss [14]. Therefore, high level perinatal grief was strongly associated with post-traumatic stress reactionss [2].
Perinatal loss women inevitablely undergo varying degrees of negative emotions [15]. On the one hand, pregnancy rendered women susceptible to emotional changes, especially for anxiety and depression, due to hormonal fluctuations, alterations in body shapes, role transitions, and concerns regarding fetal health [16]. Approximately 16 percent of women encountered depression and anxiety during pregnancy [17]. Perinatal depression and anxiety may further heighten the risk of adverse psychological outcomes after perinatal loss including postpartum depression and post-traumatic stress reactions [18, 19]. On the other hand, anxiety, depression, and post-traumatic stress reactions can all stem from neuroendocrine disorders in individuals, and their interactive effects may elucidate their interconnectedness [20]. Therefore, this study posits that perinatal depression and anxiety may have a positive impact on post-traumatic stress reactions following perinatal loss.
Perinatal grief has been verified to positively affect post-traumatic stress reactions among perinatal loss women [7, 21]. However, some studies have found that the indirect effect of grief after perinatal loss on post-traumatic stress reactions may be by influenced by an individual's perinatal emotional state such as depression and anxiety [22]. Some research found that perinatal depression and anxiety negatively impact postpartum psychological health [23]. A multi-centre cohort study demonstrated that compared with normal pregnant women, perinatal loss women with higher levels of perinatal depression and anxiety were more likely to develop post-traumatic stress reactions [24]. Besides, perinatal depression and anxiety was found positively associated with perinatal grief [25]. Based on this, the present study hypothesizes that perinatal grief may directly affect the post-traumatic stress reactions after perinatal loss and perinatal depression and anxiety acted as a mediating variable in above relationship.
Social support plays a large role in adjusting physical and psychological health after a traumatic event [26]. Social support refers to the assistance that individuals receive from their social networks, organizational relationships, and the subjective feelings of being understood, supported, and respected by others [26]. Social support was commonly perceived to exert a buffering effect on distressing emotions experienced by women who have undergone perinatal loss. Moreover, inadequate social support has been consistently linked to elevated levels of post-traumatic stress reactions in this population [27–29]. Lack of support from a partner and poor marital relations were both associated with more intense post-traumatic stress reactions [30]. High levels of perceived social support were associated with lower level of post-traumatic stress reactions among perinatal loss women [31]. Furthermore, social support served as a crucial moderating variable in relation to various factors that influence the adverse impact of individual psychological responses [32]. Therefore, this study posits that social support may play a moderating role in the relationship among perinatal grief, post-traumatic stress reactions and perinatal depression and anxiety.
Based on the above literature, the primary aim of this study was to explore the interrelationships of perinatal grief, post-traumatic stress reactions, perinatal depression and anxiety, and social support. In particular, we sought to determine whether perinatal grief was associated with post-traumatic stress reactions, and if so, whether grief affects post-traumatic stress reactions through perinatal depression and anxiety (i.e., a mediation model); whether the strength of the mediated effect through perinatal depression and anxiety varies by the varying levels of social support conditions (i.e., a moderated mediation model). We put forward the following hypotheses (Fig. 1):
H1. Perinatal grief has a direct positive impact on post-traumatic stress reactions.
H2. Perinatal grief has a direct positive impact on perinatal depression and anxiety.
H3. Perinatal depression and anxiety have a direct positive impact on post-traumatic stress reactions.
H4. Perinatal depression and anxiety play a mediating role between perinatal grief and post-traumatic stress reactions.
H5. Social support plays a moderating role in the relationship among perinatal grief, post-traumatic stress reactions and perinatal depression and anxiety.