To the best of our knowledge, this is the first study on the effects of attachment and prenatal depression on MFA in pregnant women who received antenatal education. These results are helpful for understanding the influence of attachment and depression on MFA.
In our study, a total of 38.53% of the participants suffered from prenatal depression, which is higher than that reported in the existing literature [21]. A possible explanation is that the pregnant women we included were in their third trimester and, the fear of delivery during this time was accompanied by increased fatigue, physical pain, poor sleep, and frequent urination. Another explanation is that the EPDS diagnostic criteria for depression may be different in foreign studies. Nevertheless, the results showed that prenatal depression was very common in the third trimester of pregnancy and should be given adequate attention.
According to whether the participants received prenatal education in the hospital during their latest pregnancy, our research results showed that the pregnant mothers who had received prenatal education had higher MFA and lower prenatal depression scores than those who had not received prenatal education. Our results were consistent with the results obtained in a previous study [22]. Prenatal education not only increased the rates of prenatal examinations and promoted communication with doctors but also improved women’s attitudes towards delivery [16]. In addition, prenatal education can help pregnant women accept and adapt to the role of mother[23].
Further analysis revealed that maternal attachment avoidance was negatively related to MFA quality, which is consistent with previous research results [24]. People with secure attachment are more likely to assume the role of a parent [25]. Self-reported romantic attachment predicts high avoidance scores on the parental role scale in pregnant women, and they may face difficulties in developing their maternal identity [12]. Those who attached great importance to attachment avoidance felt uncomfortable with intimacy and invalidated the attachment system [26]. In fact, when perceiving positive emotional information, people with high attachment avoidance are unable to experience positive emotions; to avoid the activation of the attachment system, they tend to deactivate their emotional channels and hide their feelings [27]. Thus, we can infer that in the third trimester, pregnant women with high avoidance may not respond to fetal movement, and as a result, the emotional experience with regard to the fetus may be relatively low.
The exploratory mediation analysis showed that low maternal attachment avoidance directly and indirectly reduced the MFA quality score through the prenatal depression score. The results suggested that an avoidance attitude toward the attachment subjects rendered them susceptible to the interference of depression symptoms, reducing emotional investment in the fetus. The possible mechanism is that the internal working model of attachment has an important impact on an individual's cognition, emotion, and behavior with regard to interpersonal communication, and the avoidance attachment model formed in childhood leads to a sense of mistrust of others in pregnant women. This internal working model is triggered by stressful events such as pregnancy and leads to depression during pregnancy, further reducing the emotional investment and energy devoted to the fetus, that is, poor MFA. Condon indicated that parental psychological variables could affect MFA quality. Moreover, attachment avoidance-related deactivation strategies are associated with depression maintenance [18]. In a recent study by Huang and colleagues, the prenatal maternal depression score affected the MFA score [28]. It seems that attachment avoidance and the prenatal depression score both affect the mother's intimate connection to the unborn fetus. However, no mediating role of the prenatal depression score was observed in attachment anxiety and attachment intensity, and a previous study showed that caregivers with a higher degree of avoidance are less responsive than those with a lower degree of avoidance [29]. Attachment quality is related to the mental health of mothers, while the intensity of attachment has nothing to do with mental health [30]. Our results revealed the relationship between attachment avoidance and the prenatal depression score and their effects on the degree of emotional communication and interaction between the mother and the fetus, further providing a basis for understanding the development of maternal-fetal relationships. In addition, prenatal depression symptoms were found to be negatively correlated with prenatal MFA [31, 32].
In prenatal screening, the timely detection of low-quality MFA and the application of effective interventions on the basis of the prenatal depression score or the type of mother attachment can help pregnant women adapt to their changing role in a timely manner. This can prevent incidents such as domestic child violence and allow women to better care for their newborn to ensure healthy and balanced development [33].
Our study has two limitations. First, this study was restricted by its cross-sectional design, and we did not track postpartum maternal and infant attachment, which should be evaluated in the next step of our work. In addition, data collection was based on a convenience sampling, so our participants may not represent the general pregnant population. However, despite these limitations of our research, our findings provide new ways insights into antenatal education and interventions.