This study contains important data about factors related to depression, anxiety, and stress in pregnant women. It is important to be aware of the factors contributing to the development of depression, anxiety, and stress, pay attention to these factors in prenatal care, and offer counseling strategies to reduce the depression, anxiety, and stress perceived by pregnant women based on the factors causing them. Therefore, these data can be used for planning antenatal care and future studies.
The present study demonstrated that female SD was a significant factor contributing to depression, anxiety, and stress. Moreover, increased severity of SD in pregnancy was associated with elevated severity of depression, anxiety, and stress. Although many studies have examined sexual function in pregnancy, few have examined SD during this period. In addition, no study has yet been conducted to investigate this factor as an influential factor in depression, anxiety, and stress during pregnancy. A study of non-pregnant samples showed a significant relationship between anxiety and stress and all aspects of sexual function, except for sexual desire and pain. It also revealed a significant association between depression and all aspects of sexual function except for sexual pain [26]. Since women with sexual problems may report concurrent SD [32], it seems that SD is also associated with anxiety, depression, and stress. On other hand, a high rate of SD in pregnancy has been reported. A study by Sarah showed that 42% of women experience SD during pregnancy, which can be in the presence or absence of a sexual problem [13]. This rate of SD is slightly higher than the rate reported in Finnish and American population-based studies of women who were not pregnant [32, 33]. It seems that SD is more common in pregnancy due to the unique features of this period. For this reason, it is important to consider the role of SD in the development of depression, anxiety, and stress, followed by providing counseling and treatment techniques that improve it.
We found that women with poor GSI were at a higher risk for depression. Indeed, we noted a significant inverse correlation between GSI score and depression and anxiety scores, such that as BI score decreased, the scores of depression and anxiety increased. In other words, having a poor GSI was associated with high severity of depression and anxiety. In this regard, satisfaction with BI in pregnancy was also recognized as an effective factor in antenatal anxiety. In a critical review of the literature, it was reported that all prospective cohort studies evaluating the impact of BI on the incidence of depression found a positive relationship between BI dissatisfaction and incidence of prenatal depression. Moreover, this review examined whether depression leads to BI dissatisfaction. It was noted that the findings of studies are inconsistent regarding the effect of depression on BI [19]. As it is known, pregnancy induces a variety of hormonal, immunologic, and metabolic changes that exert significant effects on a woman’s body. Pregnancy can trigger or intensify negative feelings about the body. Some women can be distressed by bodily changes in pregnancy. BI dissatisfaction during pregnancy can have a negative impact on both the mother and the baby [34]. One of the areas most affected by pregnancy changes is the genitals (i.e., hyperpigmentation, volva skin stretch, striae on volva, mucosal changes, etc.) [18]. Both BI dissatisfaction and poor GSI can indirectly cause stress and anxiety and affect sexual function [35, 36], and subsequently, engender SD. Many studies have reported a link between GSI and sexual function in the non-pregnant population. Since pregnant women are more prone to poor GSI due to changes in their physiology, special attention should be paid to the role of this factor in the development of mental disorders.
Planned pregnancy was revealed to be a significant factor for developing depression and stress among participants in the present study. This finding has been corroborated by another study indicating the negative effect of unplanned pregnancy on antenatal depression. Biratu et al. [37] reported that women who had not planned the current pregnancy were 2.58 times more likely to develop antenatal depression than those who had planned the pregnancy. Many studies have reported unplanned or unwanted pregnancy as a risk factor for developing depression [37–39] and stress [40]. Various studies have emphasized the role of planned pregnancy in the prevention of antenatal depression [37]. In a systematic review conducted by Alessandra et al. [41], it was shown that unplanned or unwanted pregnancy is associated with antenatal depression. Hartley et al.[42] did not find a significant association between unwanted pregnancy and antenatal depression. Unplanned pregnancy can make a pregnant woman unhappy. Unhappiness could be the result of many contributing factors such as conflicts with others, life stress, and lack of social support. Sherin et al. [43] pointed out that being unhappy with the pregnancy is another risk factor associated with antenatal depression and women who were unhappy with their pregnancy were more likely to suffer from antenatal depression.
The present study demonstrated that adverse events in previous pregnancy (for any reason) was associated with depression and stress in the current pregnancy. This finding corroborates those of previous studies indicating that women with current or past pregnancy/delivery complications, history of pregnancy loss, pregnancy termination, or stillbirth have been found to be more likely to experience antenatal depression and anxiety. In the same vein, Waqas et al. [44] showed that a history of previous negative birth experience is linked with a high likelihood of antenatal depression. Bad/negative obstetric history such as history of miscarriage, stillbirth, and preterm birth were significantly associated with the increased risk of antenatal depression. This negative obstetric history and other pregnancy complications such as hyperemesis gravidarum, hypertension, and diabetes mellitus could also pose additional stress on mothers in current pregnancy [45]. An Italian study by Agostini et al. [46] also reported that a negative experience of pregnancy was significantly associated with antenatal depression. These findings show the importance of asking all pregnant women, regardless of their cultural differences, about history of experiencing any bad events for the mother or her fetus in a previous pregnancy.
We also found that fear of fetal abortion was a significant risk factor for anxiety, which it could be due to lack of experience in becoming a mother in primiparous women or due to bad experiences and complications in previous pregnancies in multiparous women. Therefore, it is necessary to ask about the fears and worries of pregnant women in prenatal care and provide appropriate counseling to reduce these negative feelings.
Satisfaction with income was another factor closely related to the decreased risk of prenatal depression and anxiety in this study, which is consistent with the results of other studies. For example, in a study by Brittain et al. [38] in South Africa, it was found that pregnant women with low socioeconomic status were more likely to experience antenatal depression than those with a high socioeconomic status. Another study also suggested that the higher prevalence of depression among black and Hispanic mothers could be mainly due to lower income and financial problems [3]. These findings were also supported by a recent systematic review by Fekadu Dadi et al. [47], which reported that pregnant women with a history of economic difficulties were more likely to report antenatal depression. Nevertheless, family income in a study conducted in Malaysia was not associated with depression and anxiety in pregnancy [48]. This discrepancy could be due to difference in study populations and measuring income levels using different categories.
In addition, we found a higher risk of anxiety in pregnant women with increased duration of marriage. It seems that in order to better understand this factor, special attention should be paid to the role of partner support. What’s more, increased age of women was revealed to be a significant risk factor for depression and stress, which could be because aging is associated with more pregnancy complications such as preeclampsia and worry about having these complications, which may lead to higher stress in women.
Our findings support the significant role of gestational age in the development of anxiety and stress, such that increased gestational age was associated with a decrease in stress and anxiety scores. Fadzil et al. [48] showed that gestational age less than 20 weeks was associated with antenatal anxiety. The risk of antenatal anxiety disorder was 4.85 times higher among mothers below 20 weeks of gestation compared to those 20 weeks and above. The probable reason for this finding is the increase in a woman's ability to cope with the physiological process of pregnancy and the physical changes occurring in her body over time.