Mihyeon Park; Sukhee Ahn

doi:10.4040/jkan.24070

Articles

Page Path: HOME > J Korean Acad Nurs > Volume 55(1); 2025 > Article

Research Paper
Serial mediation effects of social support and antepartum depression on the relationship between fetal attachment and anxiety in high-risk pregnant couples of South Korea: Mihyeon Park¹, Sukhee Ahn²; Journal of Korean Academy of Nursing 2025;55(1):19-33.
DOI: https://doi.org/10.4040/jkan.24070
Published online: February 4, 2025

¹Department of Nursing, Baekseok Culture University, Cheonan, Korea

²College of Nursing, Chungnam National University, Daejeon, Korea

Corresponding author: Sukhee Ahn College of Nurisng, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea E-mail: sukheeahn@cnu.ac.kr

• Received: June 25, 2024 • Revised: September 2, 2024 • Accepted: October 10, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

394 Views
47 Download

prev next

Full Article

Download PDF

Abstract
Introduction
Methods
Results
Discussion
Conclusion
Article Information
References
Appendix

Abstract

Purpose
This study examined the direct effects of fetal attachment, social support, and antepartum depression on anxiety in pregnant women with high-risk pregnancy-related conditions and their husbands. Furthermore, it aimed to explore the serial mediation effects of social support and antepartum depression in the relationship between fetal attachment and anxiety.
Methods
A survey-based study was conducted among pregnant women diagnosed with high-risk pregnancy conditions at 24–32 weeks and their husbands, recruited from a pregnant women’s online community between January 20, 2021 and July 20, 2022. Data were collected from 294 individuals (147 couples) using self-report questionnaires. Correlations between variables were analyzed using the IBM SPSS software ver. 26.0 (IBM Corp.), and the mediation effects were assessed using the PROCESS macro, model 6.
Results
In the maternal model, maternal-fetal attachment directly affected anxiety (p=.005), with antepartum depression partially mediating this relationship (95% confidence interval [CI], –0.26 to –0.01). In the paternal model, paternal-fetal attachment had no direct effect on anxiety (p=.458). However, social support and antepartum depression fully mediated the relationship between paternal-fetal attachment and anxiety (95% CI, –0.14 to –0.03).
Conclusion
The findings indicate that social support in the relationship between fetal attachment and depression in high-risk pregnant women and their partners can have direct or indirect effects on the negative emotions of high-risk pregnant couples. It is necessary to assess the level of anxiety in couples experiencing high-risk pregnancies and provide comprehensive nursing interventions that address fetal attachment, social support, and antepartum depression in order to reduce anxiety.
Key words: Anxiety; Depression; High-risk; Maternal-fetal relations; Pregnancy; Social support

Introduction

In Korea, the age of marriage in 2021 is 33.7 years for men and 31.3 years for women, indicating that couples’ first marriage age is delayed, and their average age for childbirth is 33.5 years. While the proportion of women under 35 has decreased by 17% from 2010 to 2020, the number of elderly pregnant women over age 35 increased by 16.9% [1,2]. In the case of elderly pregnant women, perinatal complications and mortality rates increase proportionate to age, and the risk of premature birth increases, affecting the fetus’ well-being and life [3]. Furthermore, 20% to 30% of all pregnancies are high-risk, and the number of pregnant women treated for high-risk pregnancies has increased approximately five-fold over the past 10 years [4]. High-risk pregnancy is an obstetric condition with negative risk factors for birth outcomes that pose actual and potential risks to the health or well-being of the mother and fetus [5].

Perceptions of high-risk pregnancy may differ between women and men, but couples may experience a variety of emotional burdens and anxiety during a high-risk pregnancy [6]. Anxiety in high-risk pregnant women contributes to impaired fetal development and is a risk factor for increased physical distress and preterm birth [7]. The more severe the high-risk pregnancy complications or the poorer the fetal health, the more difficulty hospitalized high-risk pregnant women experience in maintaining close relationships with their spouse and family [8], and have anxiety levels that are twice as high as low-risk pregnant women [9]. Further, pregnant women with gestational diabetes and their spouses had higher rates of anxiety, or 32.4% and 36.6%, respectively [10]. It is expected that these women may experience high levels of anxiety due to the burden of healthcare, as they are more medically involved with frequent diagnostic testing and monitoring than low-risk pregnant women [8,11]. Correspondingly, previous studies have identified several key factors associated with anxiety among high-risk pregnant women. These factors include fetal attachment, social support, maternal depression, and spousal depression [7,12,13].

Consolidated research findings from attachment theory perspectives suggest that parents developing an emotional bond with their fetus during pregnancy can reduce the uncertainty, stress, depression, and anxiety associated with high-risk pregnancies and positively influence parental health behaviors and the adjustment to parenthood [14]. Maintaining a high-quality attachment to the fetus also has important implications for the couple’s ability to fulfill their parental role during pregnancy, contributing to the newborn’s development after birth [15]. Low parental fetal attachment during pregnancy may jeopardize the child’s emotional stability through childhood and may lead to poor interpersonal relationships [14]. This study developed a conceptual framework based on the attachment theory by psychologist John Bowlby [16,17] and a comprehensive literature review to create a hypothetical model (Appendix 1).

High-risk pregnant women may perceive pregnancy as a crisis in which they may face unexpected and uncertain circumstances, leading to lower fetal attachment, higher anxiety, and antepartum depression [18]. As negative fetal attachment is associated with postpartum depression, it is important to support parent-fetal attachment and mental health during pregnancy [14,19]. Husbands of pregnant women diagnosed with high-risk pregnancies also experience fear and grief due to the emotional burden of the diagnosis and limited coping mechanisms; this may lead them to perceive the high-risk pregnancy as an act of negligence on the part of the mother or to view the pregnancy and birth process as uncertain, making it difficult for them to develop fetal attachments and transition to parenthood [6,20].

For these high-risk pregnant women, social support can be a factor in mitigating pregnancy and labor crises. Emotional, material, and informational support, as well as professional help from healthcare providers, are also useful sources of support [21]. High-risk pregnant women may experience frequent hospital visits and, if hospitalized, exhibit higher levels of depression and anxiety, which can impact the health of the fetus and treatment outcomes [22]. Consequently, they often require more social support compared to low-risk pregnant women. Moreover, adequate social support for high-risk pregnant women has been shown to increase positive emotions, decrease negative emotions, and alleviate social isolation [23]. Specifically, informational support within social support systems is deemed crucial for women experiencing high-risk pregnancies [13,23]. Research on the social support of husbands in high-risk pregnancies is scarce. Still, a qualitative study in Turkey discovered that husbands had very little social support and did not seek help when they experienced psychological distress [6]. As husbands of women with high-risk pregnancies have fewer social networks and are more likely to rely on their partners, the less social support a pregnant woman has, the more likely she will develop depression [6,24]. In contrast, high-risk preterm women had a 10% higher rate of antepartum depression than low-risk women, and such depression increased with the severity of pregnancy complications. In terms of variable relatedness, maternal-fetal attachment in preterm labor positively relates to social support [13], and maternal-fetal attachment in high-risk pregnancies negatively relates to antepartum depression and anxiety [25].

Despite these important factors that may influence social support, antepartum depression, and anxiety, research describing the relationships among these variables has been fragmented, with most studies exploring the relationships among individual variables in women experiencing high-risk pregnancies. Similarly, although existing literature has confirmed the importance of fetal attachment for women experiencing high-risk pregnancies and their husbands in influencing social support, antepartum depression, and anxiety, research describing the relationships between these variables has been largely fragmented; most merely explore the associations between individual variables in a sample of pregnant women.

While domestic studies assessing anxiety in women experiencing high-risk pregnancies and their spouses are difficult to find, international studies have reported on couples experiencing a single pregnancy complication, such as gestational diabetes or risk of preterm birth [10,26]. In particular, antepartum depression in high-risk pregnant women is associated with depression in their husbands [26], and anxiety in husbands is also associated with gestational diabetes [10], suggesting that each spouse’s emotional state affects and is affected by the other. Thus, it is important to examine couples’ adjustment to pregnancy using data on fetal attachments, social support, antepartum depression, and anxiety in couples experiencing high-risk pregnancies as the number of women diagnosed with high-risk pregnancies increases in Korea.

This study will first determine the levels of fetal attachment, social support, antepartum depression, and anxiety in women diagnosed with high-risk pregnancies and their husbands. Then, the study will determine the effects of fetal attachment on anxiety in high-risk pregnant couples through a two-mediator serial mediation model involving social support and antepartum depression in high-risk pregnant women and their husbands at the time of the high-risk pregnancy.

This study proposes a model that fetal attachment influences the behavior and emotional states of pregnant women in high-risk pregnancies. It assumes that adequate social support (serving as a secure base) may reduce antepartum depression (emotional distress) and subsequently affect anxiety levels.

The hypotheses of the study are as follows:

H1. Fetal attachment is positively associated with social support.

H2. Fetal attachment is negatively associated with antepartum depression.

H3. Fetal attachment is negatively associated with anxiety.

H4. Social support is negatively associated with anxiety.

H5. Social support is negatively associated with antepartum depression.

H6. Antepartum depression is positively associated with anxiety.

H7. Social support significantly mediates the effect of fetal attachment on anxiety.

H8. Antepartum depression significantly mediates the effect of fetal attachment on anxiety.

H9. Social support and antepartum depression sequentially mediate the effect of fetal attachment on anxiety.

Methods

1. Study design

This study is part of a larger study exploring parenthood adjustment from pregnancy to postpartum among high-risk pregnant women and their husbands. This study uses a cross-sectional survey design to determine the effects of fetal attachment on anxiety in high-risk pregnant couples through a two-mediator serial mediation model involving social support and antepartum depression in high-risk pregnant women and their husbands at the time of the high-risk pregnancy. It is described by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines (https://www.strobe-statement.org/) [27].

2. Samples

The study sample consisted of paired pregnant women (24–32 weeks gestation) with high-risk conditions and their spouses. This gestational period, representing the mid-trimester, was chosen as it offers a relatively stable phase after the 20th week of pregnancy, allowing for assessing attachment and psychological state in high-risk pregnancies [26]. The women had high-risk pregnancy conditions, including 11 specific diseases: preterm labor, antepartum hemorrhage, preeclampsia, premature rupture of membranes, placental abruption, placenta previa, threatened abortion, polyhydramnios, oligohydramnios, incompetent internal os of the cervix, gestational diabetes mellitus, as well as advanced maternal age (≥35 years) [5]. Exclusion criteria were any diagnosed psychiatric disorders before pregnancy, diagnosed antepartum depression or anxiety during pregnancy, multiple pregnancies, or fetal anomalies during pregnancy. Due to the specific inclusion criteria and the relatively low prevalence of high-risk pregnancies compared to low-risk pregnancies, the data collection period was extended by more than 1 year to ensure an adequate sample size.

Based on an alpha (α) of 0.05, a power value of 0.80, and an effect size of f²=0.05. The effect size was calculated based on a previous study, which demonstrated a significant relationship of support and anxiety (r=–.41) and between fetal attachment and anxiety (r=–.20), fetal attachment and anxiety (r=–.30) in high-risk pregnant women report [13,28]. The minimum sample size of at least 159 participants was required. While surveys of pregnant women and their spouses had a dropout rate of more than 30% [29]; so, we recruited 206 pregnant women and 206 husbands to ensure the required sample size. After excluding 59 couples with incomplete responses or missing questions, 147 pairs of pregnant women and their husbands were used in the final analysis.

3. Measurements

1) Parent-fetal attachment

(1) Paternal-fetal attachment

Paternal-fetal attachment was measured with the Korean version of the Paternal-Fetal Attachment Scale (K-PAFAS) developed by Noh and Yeom [30]. The instrument consists of 20 items on a 5-point scale, with responses ranging from 1 (not at all) to 5 (very much). These items ask about the father’s feelings, thoughts, expectations, and behaviors toward his unborn baby. The subscales comprise four factors: bonding with the unborn child, changes in fathering behavior, perceptions of fatherhood, and expectations for the unborn child. The total scores ranged from 20 to 100, with higher scores indicating higher levels of paternal-fetal attachment. The instrument’s reliability at the time of development was .89, with a Cronbach’s α of .93 in this study [30].

(2) Maternal-fetal attachment

Maternal-fetal attachment was measured with the Korean version of the Maternal Fetal Attachment Scales developed by Cranley [31] and Kim [32]. The instrument consists of a 24-item, 4-point scale, with responses ranging from 1 (never) to 4 (always). These items examine how mothers relate to and interact with their unborn babies. The subscales are organized into five factors: distinguishing oneself from the fetus, interacting with the fetus, speculating about fetal characteristics and intentions, self-commitment, and role acceptance. The total scores ranged from 24 to 96, with higher scores indicating higher fetal attachment. The instrument’s reliability at the time of development was demonstrated by a Cronbach’s α of .92, which was also .92 in this study [32].

2) Social support

Social support was measured with the Korean translation of the Multidimensional Scale of Perceived Social Support by Zimet et al. [33]. The instrument consists of three subdomains of perceived support from friends, family, and significant others, with 12 items in total, and a 5-point scale, with responses ranging from 1 (not at all) to 5 (very much). Total scores ranged from 12 to 60, with higher scores indicating higher levels of social support. In the study by Kim and Lim [34], Cronbach’s α was .89; in this study, it was .93 for pregnant women and .94 for spouses.

3) Antepartum depression

Antepartum depression was measured with the Korean translation tool [33] of the Edinburgh Postnatal Depression Scale (EPDS) developed by Cox et al. [35]. This tool consists of 10 self-reported questions on depression, anxiety and fear, guilt, and self-harm thoughts, with a 4-point scale ranging from 0 to 3 and a total score ranging from 0 to 30, with higher scores indicating more depression. Based on a study by Kim et al. [36] in which the cutoff point was 9/10 for pregnant women in Korea, the same cutoff point was used in the current study to identify depression. Further, Cox et al. [35] reported that the instrument’s reliability at the time of development was indicated by a Cronbach’s α of .87, with .84 in a subsequent study of pregnant women [37]; this study measured .83 for pregnant women and .85 for their spouses.

4) Anxiety

Anxiety was measured with the Korean translation of the State-Trait Anxiety Inventory (STAI) by Spielberger et al. [38] and Kim and Shin [39]. This instrument measures feeling anxious, tense, nervous, or worried in the present moment and comprises 10 positive and 10 negative items. This 20-item instrument is measured on a 4-point scale, with responses ranging from 1 (not at all) to 4 (very much so); total scores range from 20 to 80, commonly classified as “no or low anxiety” (20–37), “moderate anxiety” (38–44), and “high anxiety” (45–80). The reliability of the instrument’s Korean version was indicated by a Cronbach’s ⍺ of .84, and in this study, it was .93 for pregnant women and .92 for spouses [39].

4. Data collection

Data collection for this study began after obtaining approval from the institutional review board. The research team recruited high-risk pregnant women and their husbands in pairs from an online cafe for pregnant women between January 20, 2021, and July 20, 2022. If they met the inclusion criteria, they were contacted individually, the study’s purpose and content were explained, and written informed consent was obtained from those who wished to participate. The women and their husbands were then asked to complete the questionnaire individually to minimize potential sources of bias between couples, which took approximately 20 minutes. After completing the questionnaire, the subjects were given a small reward of 10,000 Korean won.

5. Ethical considerations

Ethical review and approval for this study were approved by the institutional review board (IRB) of Chungnam National University (IRB no., 202007-SB-094-01). Written informed consent was obtained from the participants.

6. Data analysis

The data collected were analyzed using the IBM SPSS ver. 26.0 (IBM Corp.) and the PROCESS macro program (https://www.processmacro.org/download.html) [40]. Differences in the general characteristics of women and their husbands were analyzed using a chi-square test, an independent t-test, and a one-way analysis of variance, and a post-hoc analysis was performed using Scheffé’s test. Relationships among the study variables were analyzed using Pearson’s correlation coefficients. After checking the multicollinearity of the main variables for regression analysis in each of the pregnant women and husbands, a PROCESS macro, model 6 (2-mediator) [40], was applied to analyze the total, direct, and indirect effects.

Results

1. General characteristics and antepartum depression, anxiety in high-risk pregnant couples

The average age of the pregnant women in this study was 35.7±3.7 years, while the average age of their husbands was 37.4±4.5 years. Mothers aged 35 and above accounted for 66.7%. Most women, 81.0%, and men, 70.7%, were 30–39. There was a statistically significant difference in age distribution between genders (χ²=59.21, p<.001). Most participants had a high level of education, and women with a college degree or higher accounted for 94.6%, which was higher than men’s 87.1% (χ²=21.45, p<.001). A notable difference was observed in employment status, with 98.0% of men being employed compared to only 36.1% of women (χ²=127.40, p<.001).

Among the high-risk pregnancy diagnoses (multiple responses), cervical incompetency (22.4%), gestational diabetes (21.8%), and preterm labor (21.1%) were the most common and followed by placenta previa (7.5%), abruption of the placenta (7.5%), and rupture of membranes (6.1%).

2. Differences in anxiety by general characteristics in high-risk pregnant couples

Anxiety was higher among women with high-risk pregnancies when they were not working currently (t=3.29, p=.001), had experienced high physical discomfort (F=4.24, p=.016), had poor maternal health (F=25.09, p<.001); and when fetal health was poor (F=10.06, p<.001). For husbands of high-risk pregnant women, not having a job was associated with higher anxiety (t=2.91, p=.004) (Table 1).

3. Comparing fetal attachment, social support, antepartum depression, and anxiety in high-risk pregnant couples

Women with high-risk pregnancies had a maternal-fetal attachment score of 74.07 out of 96 (77.16 on a 100-point scale). Husbands of pregnant women with high-risk pregnancies had a paternal-fetal attachment score of 83.18 out of 100, with husbands scoring higher than pregnant women on attachment (t=–4.71, p<.001). Social support was 48.80 for pregnant women, similar to 48.88 for husbands (t=–0.09, p=.924). Antepartum depression was 7.81 for pregnant women, compared to 5.80 for their husbands (t=3.31, p=.001), and anxiety was 43.95 for pregnant women, compared to 39.06 for their husbands (t=4.18, p<.001).

Regarding levels of mental health, 31.3% of women and 21.8% of men were at risk for antepartum depression (EPDS score ≥10), while 43.5% of women and 34.0% of men reported high levels of anxiety (score ≥45). Although the prevalence of depression and anxiety was quite high, there were no gender differences in mental health (Table 2).

4. Association between fetal attachment, social support, and antepartum depression in high-risk pregnant couples

Among pregnant women with high-risk pregnancies and their husbands, fetal attachment positively correlated with social support (pregnant women: r=.30, p<.001; husbands: r=.48, p<.001), negatively correlated with depression (pregnant women: r=–.22, p=.006; husbands: r=–.18, p=.025), and negatively correlated with anxiety (pregnant women: r=–.35, p<.001; husbands: r=–.26, p<.001).

When we examined the study variables’ associations between pregnant women and their spouses, we found significant, positive correlations between fetal attachment (r=.17, p=.034), social support (r=.33, p<.001), antepartum depression (r=.26, p<.001), and anxiety (r=.34, p<.001) (Table 3).

5. Mediating effects of social support and antepartum depression on the relationship between fetal attachment and anxiety in high-risk pregnant couples

To examine social support and antepartum depression’s mediating effects on the relationship between fetal attachment and anxiety in pregnant women and their husbands, a serial multiple mediation model was tested using model 6 of the PROCESS macro proposed by Hayes [40]. The results are presented in tables and figures for pregnant women and their husbands, respectively (Table 4, Figure 1).

Before testing the model for anxiety in high-risk pregnant women, a Durbin-Watson statistic was calculated to confirm any autocorrelation among the error terms; the resulting value of 2.00 was close to 2, indicating that no autocorrelation exists among the error terms. To check for multicollinearity among the independent variables, the tolerance ranged from 0.86 to 0.94, all of which was greater than 0.10, and the variance inflation factor scores ranged from 1.05 to 1.15, all of which were less than 10; hence, no multicollinearity exists among the independent variables.

In the maternal model, maternal-fetal attachment significantly influenced social support (β=0.30, p<.001), antepartum depression (β=–0.20, p=.015), and anxiety (β=–0.16, p=.005), supporting hypotheses H1, H2, and H3. While social support did not directly affect antepartum depression (β=–0.04, p=.577), it exhibited a direct effect on anxiety (β=–0.11, p=.040). Concurrently, antepartum depression emerged as a robust predictor of anxiety (β=0.66, p<.001), validating H4 and H6. To assess the mediating effects of social support and antepartum depression on the fetal attachment-anxiety relationship, we employed bootstrap analysis (10,000 samples). Results revealed no indirect effect of fetal attachment on anxiety via social support (β=–0.03; 95% confidence interval [CI], –0.09 to 0.001). However, a significant indirect association between fetal attachment and anxiety through antepartum depression was observed (β=–0.14; 95% CI, –0.26 to –0.01). The serial mediating effect of social support and antepartum depression was not significant (β=–0.01; 95% CI, –0.04 to 0.02). The total effect of maternal-fetal attachment on anxiety (β=–0.28, p<.001) exceeded its direct effect (β=–0.16; 95% CI, –0.23 to –0.04), corroborating the mediating roles of social support and antepartum depression. These findings support hypothesis H8 (Table 4, Figure 1).

In the paternal model, the Durbin-Watson statistic for the autocorrelation between the error terms in the regression model was 2.23, indicating no autocorrelation. When assessing multicollinearity among the independent variables, the tolerance limits ranged from 0.70 to 0.89, and the variance expansion index ranged from 1.12 to 1.42, indicating no multicollinearity exists among the independent variables.

Paternal-fetal attachment directly affected social support (β=0.48, p<.001) but not antepartum depression (β=–0.03, p=.729) or anxiety (β=–0.05, p=.458). H1 has been supported. Social support had a direct effect on antepartum depression (β=–0.31, p<.001) and anxiety (β=–0.22, p=.001). At the same time, antepartum depression was also found to be a significant predictor of anxiety (β=0.58, p<.001). H4, H5, and H6 have been supported. To test the significance of social support and antepartum depression’s mediating effects on the relationship between paternal-fetal attachment and anxiety, we conducted 10,000 bootstraps. First, social support’s simple mediating effect on the relationship between paternal-fetal attachment and anxiety was statistically significant (β=–0.11; 95% CI, –0.18 to –0.04). Second, antepartum depression’s simple mediating effect on the relationship between paternal-fetal attachment and anxiety was not significant (β=–0.01; 95% CI, –0.13 to 0.09). Finally, the test of the social support and antepartum depression’s serial, multiple mediating effects revealed a statistically significant (β=–0.08; 95% CI, –0.14 to –0.03). H7 and H9 have been supported. The total effect of paternal-fetal attachment on anxiety, considering both social support and antepartum depression as mediators, was significant (β=–0.22, p<.001). However, paternal-fetal attachment did not have a direct effect on anxiety when the mediators were included in the model, indicating that the relationship between paternal-fetal attachment and anxiety was fully mediated by social support and antepartum depression (Table 4, Figure 1).

Discussion

This study identified social support and antepartum depression’s mediating effects on the relationship between fetal attachment and anxiety in high-risk pregnancies. As a result, while the serial mediation effect did not appear in the maternal model, an effect did appear in the paternal model, confirming gender differences.

In this study, high-risk pregnant women’s maternal-fetal attachment score of 74.07 was 9.21 points lower than the attachment score of 83.28 for low-risk pregnant women at 16 weeks gestation [41] and similar to the 76.64 reported for high-risk pregnant women at 20 weeks gestation or more [21]. This may reflect a reduced fetal attachment among women experiencing high-risk pregnancies due to the latter’s uncertainty about the fetus’ health and survival [42]. The husband’s paternal-fetal attachment score of 83.18 was 4.96 points lower than the research by Noh and Yeom [30] of 88.14. While different assessment tools were employed, standardization to a 100-point scale allows for comparative analysis. The results indicate that pregnant women scored lower (77.16) than their spouses (83.18). Furthermore, both these scores appear to be comparatively lower than those observed in low-risk pregnant women and their partners. The social support score 48.80 for high-risk pregnant women was similar to the 48.57 score for women with preterm labor [34] but higher than the 45.47 social support score for women with low-risk pregnancies [43]. The social support score of husbands of high-risk pregnant women was 48.88 points, which was higher than the 47.67 points scored by husbands of low-risk pregnant women [43]. The gap between mother’s and father’s scores is smaller in high-risk situations (0.08). Both parents report higher social support scores in high-risk pregnancies compared to low-risk ones. This suggests that subjects with various high-risk pregnancy diagnoses and those experiencing a single pregnancy complication sought and received more social support than those with low-risk pregnancies.

High-risk pregnant women’s antepartum depression score was 7.81, with an incidence of 31.3%, which was slightly higher than 6.82, with an incidence of 23.6% of low-risk pregnant women [44]. The depression score for husbands is 5.80, which is 1.20 points higher than the 4.60 score for husbands of low-risk pregnant women [45]. The husband’s anxiety score was 39.06, compared to 34.59 for the husbands of low-risk pregnant women [46]. Both antepartum depression and anxiety scores were higher for mothers than for fathers. High levels of anxiety (scores of 45 or higher) were observed in 43.5% of high-risk pregnant women, consistent with anxiety levels being twice as high compared to low-risk pregnant women [9]. These results affirm that the prevalence of depression and anxiety tends to be greater among women and men undergoing high-risk pregnancies compared to those with low-risk pregnancies [9-11,26,47]. Hospitalized high-risk pregnant women reported higher levels of antepartum depression and anxiety than in the low-risk pregnancy group [42], thus indicating that hospitalization during pregnancy constitutes a contributing factor to antepartum depression and anxiety. This suggests that both outpatient and hospitalized high-risk pregnant women are at increased risk for depression and anxiety, and early and periodical screenings and strategies for social-psychological interventions are needed to reduce depression and alleviate anxiety.

The factors associated with anxiety among women with high-risk pregnancies were not having a job, having high physical discomfort, and having poor maternal health and fetal health. This is consistent with previous studies that anxiety among high-risk pregnant women was associated with not having a job, poor subjective health, and poor fetal health [48]. This is likely because financial difficulties and concerns about maternal and fetal health and safety during pregnancy trigger anxiety. Although no statistical difference was observed in antepartum depression and anxiety levels between high-risk pregnant women and their spouses, there was a 9.5% higher prevalence of the depression-risk group and high-anxiety group among women. This finding corroborates the study by Chae [49], suggesting that even among low-risk pregnant women, levels of prenatal depression and anxiety tend to surpass those of their spouses. Thus, pregnant women not only undergo typical physiological and psychological adaptations associated with pregnancy but also contend with the direct experience of high-risk pregnancy, thereby encountering heightened levels of negative emotions.

The study variables significantly correlated with each other for both pregnant women and husbands experiencing high-risk pregnancies. This is consistent with research demonstrating that maternal-fetal attachment positively relates to social support and that maternal-fetal attachment and social support negatively relate to antepartum depression and anxiety in high-risk pregnancies [13,18]. Furthermore, each study variable was positively correlated between women experiencing high-risk pregnancies and their husbands. This is consistent with a study that reported that fetal attachment and anxiety are mutually influenced in couples experiencing high-risk pregnancies and that the pregnant woman’s antepartum depression correlated with that of her husband, suggesting that each couple’s depressive feelings affect the other [26]. It can be interpreted as a result that the social dynamics, emotional experiences, and psychological states of pregnant women and their husbands may influence each other. Considering these results, we suggest that comprehensive informational and psychological support is crucial not only for high-risk pregnant women but also for these couples through such a couple-centered education [50]. Interventions should be tailored to address the specific needs identified in our study, such as financial concerns, communication, and health-related worries. Cognitive-behavioral therapy, stress management techniques, and personalized counseling could be effective in mitigating anxiety and depression [51].

Results confirming the double mediating effects of social support and antepartum depression on the relationship between maternal-fetal attachment and anxiety, did not significantly mediate the relationship between maternal-fetal attachment and anxiety. However, antepartum depression emerged as a significant mediator, with higher maternal-fetal attachment associated with lower levels of antepartum depression, which in turn led to decreased anxiety. The serial multiple mediation analysis, considering the combined effects of social support and antepartum depression, did not yield significant results. This suggests that the mediating effect on anxiety did not follow a sequential path through both social support and antepartum depression. Despite this, the total effect of maternal-fetal attachment on anxiety, accounting for both social support and antepartum depression as mediators, was significant and larger than the direct effect of maternal-fetal attachment on anxiety. This confirms the presence of mediating effects, primarily through antepartum depression, in the relationship between maternal-fetal attachment and anxiety. Examining the effects of fetal attachment, social support, and antepartum depression on anxiety in women with high-risk pregnancies, we found that maternal-fetal attachment negatively and directly affected anxiety, social support mediated the relationship between maternal-fetal attachment and anxiety, and antepartum depression mediated the relationship between maternal-fetal attachment and anxiety. Hence, social support for high-risk pregnant women moderates the relationship between maternal-fetal attachment and anxiety, while antepartum depression increases anxiety. These findings are limited by the lack of studies of high-risk pregnant women using the same instrument as this study. However, the findings are similar to those of a previous study reporting that social support partially mediated the relationship between fetal attachment and depression in low-risk pregnant women, ultimately reducing depression, and social support may directly affect anxiety, reducing anxiety [52]. This suggests that social support is important for pregnant women and effectively reduces depression and anxiety; however, studies are lacking that verify social support’s mediating effect among high-risk pregnant women.

The double mediation effect in the paternal model results showed that paternal-fetal attachment had no direct effect on antepartum depression and anxiety. However, full mediation effects occurred through social support and antepartum depression in the relationship between paternal-fetal attachment and anxiety. Therefore, paternal-fetal attachment may influence anxiety through the mediation of social support and antepartum depression, with positive social support reducing anxiety but antepartum depression increasing it. Direct comparisons are difficult because studies have not used the same instruments to examine social support and antepartum depression’s mediating effects on the relationship between paternal-fetal attachment and anxiety in husbands of high-risk pregnant women. However, a study of 93 couples with low-risk pregnancies couples in Germany found that paternal-fetal attachment did not directly affect anxiety in fathers [53]. A systematic review revealed that poor spousal social support during pregnancy can lead to depression not only during pregnancy but also in the postpartum period [20]. Hence, researchers must depart from existing studies that perceive husbands of high-risk pregnant women as supporters of their wives and recognize that husbands also need social support to facilitate their adaptation to the pregnancy process and are vulnerable to antepartum depression and anxiety. Husbands of high-risk pregnant women, often limited in their access to medical professionals, need comprehensive support [54]. This includes accurate, up-to-date medical information about high-risk pregnancies, crucial for informed support [6]. Equally important is emotional support through peer networks of other husbands in similar situations. These groups facilitate experience sharing and coping strategies and provide a safe space for expressing concerns, significantly contributing to the men’s psychological well-being [54]. The elucidation of the sequential mediating effects of social support and antepartum depression provides valuable insights for healthcare professionals.

These findings can inform the development of targeted interventions to support expectant fathers, potentially leading to improved outcomes for the entire family unit. Further, antepartum care should approach pregnant women and their husbands as a family unit. Positive perceptions of social support and interventions to promote mental health are needed to strengthen fetal attachment and manage anxiety in high-risk pregnant women and their husbands. The need exists for couple-centered antepartum education rather than targeting only the pregnant woman. Nurses caring for high-risk pregnant women should identify high-risk pregnant women and their husbands as a family unit and regularly assess their prenatal attachment and anxiety levels to determine if they are candidates for intervention at each prenatal visit. By providing these couples with education and guidance on understanding high-risk pregnancies, building a relationship with their unborn child, seeking social support, and managing their emotions, nurses could help reduce antepartum depression and anxiety.

This study also includes some limitations. As the study was conducted during the coronavirus disease 2019 pandemic, anxiety levels should be interpreted with caution given the psychology during a period in which pregnant women experienced a heightened risk of coronavirus infection and restricted activity. The lack of consideration of outpatient versus hospitalized subjects and the unequal sample sizes for each of the 11 high-risk pregnancy conditions should be used with caution in interpreting the results. Despite these limitations, this study differs from other studies in that it recruited high-risk couples to simultaneously evaluate both the woman’s and husband’s adjustment to pregnancy and identified the differences in these adjustments by checking for correlations of study variables between couples. Given these limitations, future studies should compare whether the high-risk pregnancy experience differs by high-risk pregnancy diagnosis and whether the experience differs between inpatient and outpatient treatment groups. Future research should further explore the dynamics of emotional synchrony and mutual influence in couples facing high-risk pregnancies. Longitudinal studies are also needed to determine how these relationships evolve and their long-term impact on family well-being. Additionally, research should aim to expand the scope and generalize the results by including high-risk groups at various levels and diverse populations.

The demonstrated serial mediation effect suggests that interventions aimed at enhancing fetal attachment may indirectly reduce anxiety by improving perceived social support and decreasing antepartum depression. This finding has important implications for clinical practice, suggesting that comprehensive interventions addressing fetal attachment, social support, and antepartum depression may be more effective in managing anxiety in high-risk pregnancies than those targeting these factors in isolation. Nursing interventions for high-risk pregnancies should include couple-centered education, with joint sessions on coping with the challenges of pregnancy and improving communication. Emotional support programs, such as individual and group counselling with a focus on cognitive behavioral therapy, should be provided to address stress. Peer support networks for fathers will facilitate sharing of experiences and guidance. In addition, practical support should be provided, including resources for managing household tasks, medical appointments and preparing for parenthood, to reduce stress for both parents.

Conclusion

The present study discovered that for mothers in high-risk pregnancies and in the relationship between fetal attachment and anxiety, fetal attachment directly affected anxiety, with higher fetal attachment reducing anxiety through higher social support and lower antepartum depression. For husbands, fetal attachment had no direct effect on anxiety in the fetal attachment-anxiety relationship, but higher fetal attachment reduced anxiety through higher social support, and such social support reduced anxiety through lower antepartum depression. In women undergoing high-risk pregnancies and their partners, the prevalence of antepartum depression and heightened anxiety was significantly higher compared to those in the low-risk pregnancy group. Moreover, within the high-risk cohort, the rates of antepartum depression and anxiety were disproportionately higher among the women than their partners. Consequently, this indicates a crucial need for systematic screening and early intervention for both depression and anxiety in couples experiencing high-risk pregnancies. This indicates that social support may directly and indirectly affect negative emotions in couples with high-risk pregnancies. Therefore, it is suggested that an approach that includes spouses, as well as women experiencing high-risk pregnancies, is needed to assess their anxiety levels early and develop and implement social psychological nursing interventions and social support enhancement strategies to reduce anxiety during pregnancy.

Article Information

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgements

None.

Funding

This work was supported by the National Research Foundation of Korea fund in 2020-2024 (NRF no., 2020R1A2C201086511).

Data Sharing Statement

Please contact the corresponding author for data availability.

Author Contributions

Conceptualization or/and Methodology: MP, SA. Data curation or/and Analysis: MP, SA. Funding acquisition: SA. Investigation: MP, SA. Project administration or/and Supervision: SA. Resources or/and Software: MP, SA. Validation: MP, SA. Visualization: MP. Writing original draft or/and Review & Editing: MP, SA. Final approval of the manuscript: MP, SA.

Fig. 1.

Serial mediating effect in high-risk pregnant women and men. (A) Model for women. (B) Model for men. c’ (c), direct effect (total effect).

All coefficients are presented as standard effects: *p<.05, **p<.01, and ***p<.001.

Table 1.

Differences in anxiety according to subjects’ characteristics in high-risk pregnancy couples (N=294)

Characteristic	Women (n=147)			Men (n=147)
Characteristic	No. (%)	Mean±SD	t or F (p)	No. (%)	Mean±SD	t or F (p)
Age (yr)			0.42 (.658)			1.89 (.154)
≤29	5 (3.4)	42.8±10.41		1 (0.7)	38.0±0.00
30–39	119 (81.0)	44.3±10.41		104 (70.7)	38.0±8.82
≥40	23 (15.6)	42.2±9.41		42 (28.6)	41.5±11.61
Education			1.22 (.300)			0.12 (.887)
High school	8 (5.4)	42.25±8.14		19 (12.9)	39.79±7.65
College	104 (70.8)	44.80±10.66		101 (68.7)	39.11±10.02
Graduate	35 (23.8)	41.83±9.35		27 (18.4)	38.37±10.35
Working status			3.29 (.001)			2.91 (.004)
Working	53 (36.1)	40.36±10.14		144 (98.0)	38.77±9.50
Not working/parental leave	94 (63.9)	45.97±9.82		3 (2.0)	55.00±11.53
Monthly income (1 million KRW)			1.91 (.058)			0.25 (.805)
≤399	43 (29.3)	46.44±8.76			39.37±8.66
≥400	104 (70.7)	42.95±10.75			38.93±10.22
Planned pregnancy			–1.45 (.149)			0.45 (.653)
Yes	112 (76.2)	43.27±9.80			39.69±9.68
No	35 (23.8)	46.14±11.53			37.06±9.88
Physical discomfort (0–100)			4.24 (.016)^a<b,c
Low (0–33)^a	13 (8.9)	37.85±10.65
Moderate (34–66)^b	45 (30.6)	42.36±9.59
High (67–100)^c	89 (60.5)	45.65±10.18
Mother’s health status			25.09 (<.001)^a,b<c
Good^a	37 (25.2)	37.73±7.15
Moderate^b	61 (41.5)	42.16±8.50
Poor^c	49 (33.3)	50.88±10.46
Fetus health status			10.06 (<.001)^a<c
Good^a	105 (71.4)	41.71±9.17
Moderate^b	39 (26.5)	49.33±11.04
Poor^c	3 (2.1)	52.67±7.77

SD, standard deviation; KRW, Korean won.

Table 2.

Differences in study variables between women and men who experienced high-risk pregnancy (N=294)

Variable	Women (n=147)	Men (n=147)	t or χ²	p
Fetal attachment	77.16±10.04	83.18±11.77	–4.71	<.001
Social support	48.80±7.56	48.88±7.16	–0.09	.924
Antepartum depression	7.81±5.20	5.80±5.18	3.31	.001
EPDS score			3.42	.064
<10	101 (68.7)	115 (78.2)
≥10 (at risk)	46 (31.3)	32 (21.8)
Anxiety	43.95±10.27	39.06±9.76	4.18	<.001
Anxiety score			2.80	.094
<45	83 (56.5)	97 (66.0)
≥45 (high)	64 (43.5)	50 (34.0)

Values are presented as mean±standard deviation or number (%). The fetal attachment score for the woman in the pair, normalized to a 100-point scale.

EPDS, Edinburgh Postnatal Depression Scale.

Table 3.

Relationships among fetal attachment, social support, antepartum depression, and anxiety in women and men who experienced high-risk pregnancy (N=294)

Women	Men
	Fetal attachment		Social support		Antenatal depression		Anxiety
	r	p	r	p	r	p	r	p
Fetal attachment	.17^a)	.034	.48	<.001	–.18	.025	–.26	.001
Social support	.30	<.001	.33^a)	<.001	–.32	<.001	–.44	<.001
Antepartum depression	–.22	.006	–.11	.176	.26^a)	.001	.66	<.001
Anxiety	–.35	<.001	–.24	.003	.72	<.001	.34^a)	<.001

The left row shows the correlation coefficient between study variables in women with high-risk pregnancies. The upper column shows the correlation coefficient between variables measured in the husbands (men) of high-risk pregnant women.

^a)Correlations assessed between males’ and females’ reports are shown in the blank diagonal (147 couples).

Table 4.

Mediation effects of social support and antepartum depression in the relationship between fetal attachment and anxiety in women and men who experienced high-risk pregnancy (N=294)

Variable	Women (n=147)				Men (n=147)
Variable	β	t	p	95% CI	β	t	p	95% CI
Direct effect
Fetal attachment (X) → social support (M1)	0.30	3.90	<.001	0.09 to 0.27	0.48	6.75	<.001	0.21 to 0.38
Fetal attachment (X)→ antepartum depression (M2)	–0.20	–2.46	.015	–0.15 to –0.01	–0.03	–0.34	.729	–0.09 to 0.06
Social support (M1) → antepartum depression (M2)	–0.04	–0.55	.577	–0.14 to 0.08	–0.31	–3.47	<.001	–0.35 to –0.09
Fetal attachment (X) → anxiety (Y)	–0.16	–2.81	.005	–0.23 to –0.04	–0.05	–0.74	.458	–0.15 to 0.06
Social support (M1) → anxiety (Y)	–0.11	–2.06	.040	–0.31 to –0.01	–0.22	–3.21	.001	–0.50 to –0.11
Antepartum depression (M2) → anxiety (Y)	0.66	11.86	<.001	1.10 to 1.54	0.58	9.26	<.001	0.85 to 1.32
Indirect effect
Total	–0.18			–0.31 to –0.06	–0.21			–0.35 to –0.08
Indirect 1: fetal attachment (X) → social support (M1) → anxiety (Y)	–0.03			–0.09 to 0.09	–0.11			–0.18 to –0.04
Indirect 2: fetal attachment (X) → antepartum depression (M2) → anxiety (Y)	–0.14			–0.26 to –0.01	–0.01			–0.13 to 0.09
Indirect 3: fetal attachment (X) → social support (M1) → antepartum depression (M2) → anxiety (Y)	–0.01			–0.04 to 0.02	–0.08			–0.14 to –0.03
Total effect
Fetal attachment (X) → anxiety (Y)	–0.28	–4.54	<.001	–0.41 to –0.16	–0.22	–3.36	<.001	–0.35 to –0.09

CI, confidence interval.

References

1. Health Insurance Review and Assessment Service. Marriage divorce statistics 2022 [Internet]. Statistics Korea; 2022 [cited 2023 Sep 1]. Available from: https://kostat.go.kr/board.es?mid=a10301010000&bid=204&list_no=424356&act=view&mainXml=Y
2. Health Insurance Review and Assessment Service. Birth statistics 2021 [Internet]. Statistics Korea; 2022 [cited 2023 Sep 1]. Available from: https://kostat.go.kr/board.es?mid=a10301010000&bid=204&list_no=426806&act=view&mainXml=Y
3. Choi H, Nho JH, Yi N, Park S, Kang B, Jang H. Maternal, infant, and perinatal mortality statistics and trends in Korea between 2018 and 2020. Korean J Women Health Nurs. 2022;28(4):348-357. https://doi.org/10.4069/kjwhn.2022.12.23Article PubMed PMC
4. Health Insurance Review and Assessment Service (HIRA). Statistics of national diseases of interest [Internet]. HIRA; 2020 [cited 2023 Sep 1]. Available from: https://opendata.hira.or.kr/op/opc/olapMfrnIntrsIlnsInfoTab1.do
5. Hwang JY. Reclassification of high-risk pregnancy for maternal-fetal healthcare providers. J Korean Soc Matern Child Health. 2020;24(2):65-74. https://doi.org/10.21896/jksmch.2020.24.2.65Article
6. Unlu Bidik N, Hamlaci Baskaya Y. Expectant fathers’ perceptions towards high-risk pregnancy and experiences in this period: a study of hermeneutic phenomenology. Appl Nurs Res. 2022;68:151639. https://doi.org/10.1016/j.apnr.2022.151639Article PubMed
7. Göbel A, Stuhrmann LY, Harder S, Schulte-Markwort M, Mudra S. The association between maternal-fetal bonding and prenatal anxiety: an explanatory analysis and systematic review. J Affect Disord. 2018;239:313-327. https://doi.org/10.1016/j.jad.2018.07.024Article PubMed
8. Park M, Ahn S. An explanatory model of quality of life in high-risk pregnant women in Korea: a structural equation model. Korean J Women Health Nurs. 2023;29(4):302-316. https://doi.org/10.4069/kjwhn.2023.11.13.1Article PubMed PMC
9. Shariatpanahi M, Faramarzi M, Barat S, Farghadani A, Shirafkan H. Prevalence and risk factors of prenatal anxiety disorders: a cross-sectional study. Health Sci Rep. 2023;6(8):e1491. https://doi.org/10.1002/hsr2.1491Article PubMed PMC
10. Han RR, Xiang ZX, Zhang SH, Gao LL. Predictors of anxiety among pregnant women with gestational diabetes mellitus and their partners: the mediating role of marital satisfaction. Int J Nurs Pract. 2024;30(1):e13155. https://doi.org/10.1111/ijn.13155Article PubMed
11. Smorti M, Ginobbi F, Simoncini T, Pancetti F, Carducci A, Mauri G, et al. Anxiety and depression in women hospitalized due to high-risk pregnancy: an integrative quantitative and qualitative study. Curr Psychol. 2023;42(7):5570-5579. https://doi.org/10.1007/s12144-021-01902-5Article
12. Hajikhani NA, Ozgoli G, Pourebrahim T, Mehrabi Y. Predictors of mental health during high-risk pregnancy. Crescent J Med Biol Sci. 2020;7(1):54.
13. Yoo Y, Park H. Effect of social support, resilience, and fetal attachment on state anxiety of pregnant women with preterm labor. J Korea Acad Ind Coop Soc. 2023;24(2):133-144. https://doi.org/10.5762/KAIS.2023.24.2.133Article
14. Papapetrou C, Panoulis K, Mourouzis I, Kouzoupis A. Pregnancy and the perinatal period: the impact of attachment theory. Psychiatriki. 2020;31(3):257-270. https://doi.org/10.22365/jpsych.2020.313.257Article PubMed
15. Branjerdporn G, Meredith P, Strong J, Garcia J. Associations between maternal-foetal attachment and infant developmental outcomes: a systematic review. Matern Child Health J. 2017;21(3):540-553. https://doi.org/10.1007/s10995-016-2138-2Article PubMed
16. Shen F, Liu Y, Brat M. Attachment, self-esteem, and psychological distress: a multiple-mediator model. Professional Counselor. 2021;11(2):129-142. https://doi.org/10.15241/fs.11.2.129Article
17. Bretherton I. Attachment theory: retrospect and prospect. Monogr Soc Res Child Dev. 1985;50(1-2):3-35. https://doi.org/10.2307/3333824Article
18. Palma E, Armijo I, Cifuentes J, Ambiado S, Rochet P, Díaz B, et al. Hospitalisation in high-risk pregnancy patients: is prenatal attachment affected? J Reprod Infant Psychol. 2021;39(1):30-42. https://doi.org/10.1080/02646838.2020.1740661Article PubMed
19. Liu CH, Hyun S, Mittal L, Erdei C. Psychological risks to mother-infant bonding during the COVID-19 pandemic. Pediatr Res. 2022;91(4):853-861. https://doi.org/10.1038/s41390-021-01751-9Article PubMed PMC
20. Baldwin S, Malone M, Sandall J, Bick D. Mental health and wellbeing during the transition to fatherhood: a systematic review of first time fathers’ experiences. JBI Database System Rev Implement Rep. 2018;16(11):2118-2191. https://doi.org/10.11124/JBISRIR-2017-003773Article PubMed PMC
21. Kang DI, Park E. Do taegyo practices, self-esteem, and social support affect maternal-fetal attachment in high-risk pregnant women?: a cross-sectional survey. Korean J Women Health Nurs. 2022;28(4):338-347. https://doi.org/10.4069/kjwhn.2022.12.16Article PubMed PMC
22. Kim EM, Hong S. Impact of uncertainty on the anxiety of hospitalized pregnant women diagnosed with preterm labor: focusing on mediating effect of uncertainty appraisal and coping style. J Korean Acad Nurs. 2018;48(4):485-496. https://doi.org/10.4040/jkan.2018.48.4.485Article PubMed
23. Kozel E, Barnoy S, Itzhaki M. Emotion management of women at risk for premature birth: the association with optimism and social support. Appl Nurs Res. 2022;64:151568. https://doi.org/10.1016/j.apnr.2022.151568Article PubMed
24. Beesley A, Karwatzki E, Sullivan K. Anxiety and depression symptoms in fathers during their partner’s pregnancy: how does this impact paternal fetal attachment? J Prenat Perinat Psychol Health. 2019;33(3):221.
25. Calli B, Dikmen HA. The relationship between spousal support and depression, anxiety, stress, and prenatal attachment in high-risk pregnancies. Ann Med Res. 2023;30(6):692-698. https://doi.org/10.5455/annalsmedres.2023.03.070Article
26. Pisoni C, Garofoli F, Tzialla C, Orcesi S, Spinillo A, Politi P, et al. Complexity of parental prenatal attachment during pregnancy at risk for preterm delivery. J Matern Fetal Neonatal Med. 2016;29(5):771-776. https://doi.org/10.3109/14767058.2015.1017813Article PubMed
27. Strobe checklists: cross-sectional studies [Internet]. STROBE; 2023 [cited 2023 Sep 1]. Available from: https://www.strobe-statement.org/
28. Lee SH, Lee EY. The Influence of anxiety and dyadic adjustment on maternal-fetal attachment in high-risk pregnant women. Int J Softw Eng Its Appl. 2015;9(12):361-372. https://doi.org/10.14257/ijseia.2015.9.12.32Article
29. Alves S, Fonseca A, Canavarro MC, Pereira M. Dyadic coping and dyadic adjustment in couples with women with high depressive symptoms during pregnancy. J Reprod Infant Psychol. 2018;36(5):504-518. https://doi.org/10.1080/02646838.2018.1490496Article PubMed
30. Noh NI, Yeom HA. Development of the Korean Paternal-Fetal Attachment Scale (K-PAFAS). Asian Nurs Res (Korean Soc Nurs Sci). 2017;11(2):98-106. https://doi.org/10.1016/j.anr.2017.05.001Article PubMed
31. Cranley MS. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res. 1981;30(5):281-284. https://doi.org/10.1097/00006199-198109000-00008Article PubMed
32. Kim GY. Effects on maternal-infant attachment by the taegyo perspective prenatal class [master’s thesis]. Seoul, Yonsei University. 2000.
33. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52(1):30-41. https://doi.org/10.1207/s15327752jpa5201_2Article
34. Kim YK, Lim KH. Risk factors for premature birth among premature obstetric labor women: a prospective cohort study. Korean J Women Health Nurs. 2018;24(3):233-242. https://doi.org/10.4069/kjwhn.2018.24.3.233Article PubMed
35. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786. https://doi.org/10.1192/bjp.150.6.782Article PubMed
36. Kim YK, Hur JW, Kim KH, Oh KS, Shin YC. Clinical application of Korean version of Edinburgh Postnatal Depression Scale. J Korean Neuropsychiatr Assoc. 2008;47(1):36-44.
37. Koh M, Ahn S, Kim J, Park S, Oh J. Pregnant women’s antenatal depression and influencing factors. Korean J Women Health Nurs. 2019;25(1):112-123. https://doi.org/10.4069/kjwhn.2019.25.1.112Article PubMed
38. Spielberger CD, Gonzalez-Reigosa F, Martinez-Urrutia A, Natalicio LF, Natalicio DS. The state-trait anxiety inventory. Interam J Psychol [Internet]. 1971 [cited 2023 Sep 1];5(3-4):145-158. Available from: https://journal.sipsych.org/index.php/IJP/article/view/620/524
39. Kim CT, Shin DK. A study based on the standardization of the STAI for Korea. New Med J. 1978;21(11):69-75.
40. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. 2nd ed. Guilford publications; 2017.
41. Kang SK, Chung MR. The relationship between pregnant woman's stress, temperament and maternal-fetal attachment. Korean J Hum Ecol. 2012;21(2):213-223. https://doi.org/10.5934/KJHE.2012.21.2.213Article
42. Yoon SH, Sung MH. Does family support mediate the effect of anxiety and depression on maternal-fetal attachment in high-risk pregnant women admitted to the maternal-fetal intensive care unit? Korean J Women Health Nurs. 2021;27(2):104-112. https://doi.org/10.4069/kjwhn.2021.05.14Article PubMed PMC
43. Kim JH, Song YA. Health promoting behavior in pregnant couples: actor-partner interdependence model analysis. J Korean Acad Nurs. 2017;47(4):467-475. Korean. https://doi.org/10.4040/jkan.2017.47.4.467Article PubMed
44. Seo HJ, Song JE, Lee Y, Ahn JA. Effects of stress, depression, and spousal and familial support on maternal identity in pregnant women. Korean J Women Health Nurs. 2020;26(1):84-92. https://doi.org/10.4069/kjwhn.2020.03.17Article PubMed PMC
45. Oh J, Ahn S. Predictors of antenatal depression in pregnant couples. Clin Nurs Res. 2022;31(5):881-890. https://doi.org/10.1177/10547738211065238Article PubMed
46. Kannenberg K, Weichert J, Rody A, Banz-Jansen C. Treatment-associated anxiety among pregnant women and their partners: what is the influence of sex, parity, age and education? Geburtshilfe Frauenheilkd. 2016;76(7):809-813. https://doi.org/10.1055/s-0042-101546Article PubMed PMC
47. Hajikhani NA, Ozgoli G, Pourebrahim T, Mehrabi Y, Khoori E. Characterizing mental health status of couples in high-risk pregnancy and its relevant characteristics. Int J Womens Health Reprod Sci. 2018;6(4):465-470. https://doi.org/10.15296/ijwhr.2018.77Article
48. Chen J, Cai Y, Liu Y, Qian J, Ling Q, Zhang W, et al. Factors associated with significant anxiety and depressive symptoms in pregnant women with a history of complications. Shanghai Arch Psychiatry. 2016;28(5):253-262. https://doi.org/10.11919/j.issn.1002-0829.216035Article PubMed PMC
49. Chae JY. The influence of pregnant couples’ attachment representation for parents of origin on their psychological symptoms. Fam Environ Res. 2019;57(1):41-50. https://doi.org/10.6115/fer.2019.004Article
50. Koh M, Kim J, Yoo H, Kim SA, Ahn S. Development and application of a couple-centered antenatal education program in Korea. Korean J Women Health Nurs. 2021;27(2):141-152. https://doi.org/10.4069/kjwhn.2021.06.20Article PubMed PMC
51. Hopkins J, Miller JL, Butler K, Gibson L, Hedrick L, Boyle DA. The relation between social support, anxiety and distress symptoms and maternal fetal attachment. J Reprod Infant Psychol. 2018;36(4):381-392. https://doi.org/10.1080/02646838.2018.1466385Article PubMed
52. Zhou XL, Liu H, Li XH, Li F, Zhang SM, Zhang SR. Mediating effects of social support between antenatal depression and fear of childbirth among nulliparous woman. Ann Palliat Med. 2021;10(6):6399-6409. https://doi.org/10.21037/apm-21-854Article PubMed
53. Göbel A, Barkmann C, Arck P, Hecher K, Schulte-Markwort M, Diemert A, et al. Couples’ prenatal bonding to the fetus and the association with one’s own and partner’s emotional well-being and adult romantic attachment style. Midwifery. 2019;79:102549. https://doi.org/10.1016/j.midw.2019.102549Article PubMed
54. Jackson K, Erasmus E, Mabanga N. Fatherhood and high-risk pregnancy: a scoping review. BMC Pregnancy Childbirth. 2023;23(1):168. https://doi.org/10.1186/s12884-023-05422-xArticle PubMed PMC

Appendix

Appendix 1.

Conceptural framework of this study. c’ (c), direct effect (total effect).

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Serial mediation effects of social support and antepartum depression on the relationship between fetal attachment and anxiety in high-risk pregnant couples of South Korea

J Korean Acad Nurs. 2025;55(1):19-33. Published online February 4, 2025

DOI: https://doi.org/10.4040/jkan.24070

XML Download

Figure

We recommend

Serial mediation effects of social support and antepartum depression on the relationship between fetal attachment and anxiety in high-risk pregnant couples of South Korea

Fig. 1. Serial mediating effect in high-risk pregnant women and men. (A) Model for women. (B) Model for men. c’ (c), direct effect (total effect).All coefficients are presented as standard effects: *p<.05, **p<.01, and ***p<.001.

Fig. 1.

Serial mediation effects of social support and antepartum depression on the relationship between fetal attachment and anxiety in high-risk pregnant couples of South Korea

Characteristic	Women (n=147)			Men (n=147)
Characteristic	No. (%)	Mean±SD	t or F (p)	No. (%)	Mean±SD	t or F (p)
Age (yr)			0.42 (.658)			1.89 (.154)
≤29	5 (3.4)	42.8±10.41		1 (0.7)	38.0±0.00
30–39	119 (81.0)	44.3±10.41		104 (70.7)	38.0±8.82
≥40	23 (15.6)	42.2±9.41		42 (28.6)	41.5±11.61
Education			1.22 (.300)			0.12 (.887)
High school	8 (5.4)	42.25±8.14		19 (12.9)	39.79±7.65
College	104 (70.8)	44.80±10.66		101 (68.7)	39.11±10.02
Graduate	35 (23.8)	41.83±9.35		27 (18.4)	38.37±10.35
Working status			3.29 (.001)			2.91 (.004)
Working	53 (36.1)	40.36±10.14		144 (98.0)	38.77±9.50
Not working/parental leave	94 (63.9)	45.97±9.82		3 (2.0)	55.00±11.53
Monthly income (1 million KRW)			1.91 (.058)			0.25 (.805)
≤399	43 (29.3)	46.44±8.76			39.37±8.66
≥400	104 (70.7)	42.95±10.75			38.93±10.22
Planned pregnancy			–1.45 (.149)			0.45 (.653)
Yes	112 (76.2)	43.27±9.80			39.69±9.68
No	35 (23.8)	46.14±11.53			37.06±9.88
Physical discomfort (0–100)			4.24 (.016)^a<b,c
Low (0–33)^a	13 (8.9)	37.85±10.65
Moderate (34–66)^b	45 (30.6)	42.36±9.59
High (67–100)^c	89 (60.5)	45.65±10.18
Mother’s health status			25.09 (<.001)^a,b<c
Good^a	37 (25.2)	37.73±7.15
Moderate^b	61 (41.5)	42.16±8.50
Poor^c	49 (33.3)	50.88±10.46
Fetus health status			10.06 (<.001)^a<c
Good^a	105 (71.4)	41.71±9.17
Moderate^b	39 (26.5)	49.33±11.04
Poor^c	3 (2.1)	52.67±7.77

Variable	Women (n=147)	Men (n=147)	t or χ²	p
Fetal attachment	77.16±10.04	83.18±11.77	–4.71	<.001
Social support	48.80±7.56	48.88±7.16	–0.09	.924
Antepartum depression	7.81±5.20	5.80±5.18	3.31	.001
EPDS score			3.42	.064
<10	101 (68.7)	115 (78.2)
≥10 (at risk)	46 (31.3)	32 (21.8)
Anxiety	43.95±10.27	39.06±9.76	4.18	<.001
Anxiety score			2.80	.094
<45	83 (56.5)	97 (66.0)
≥45 (high)	64 (43.5)	50 (34.0)

Women	Men
	Fetal attachment		Social support		Antenatal depression		Anxiety
	r	p	r	p	r	p	r	p
Fetal attachment	.17^a)	.034	.48	<.001	–.18	.025	–.26	.001
Social support	.30	<.001	.33^a)	<.001	–.32	<.001	–.44	<.001
Antepartum depression	–.22	.006	–.11	.176	.26^a)	.001	.66	<.001
Anxiety	–.35	<.001	–.24	.003	.72	<.001	.34^a)	<.001

Variable	Women (n=147)				Men (n=147)
Variable	β	t	p	95% CI	β	t	p	95% CI
Direct effect
Fetal attachment (X) → social support (M1)	0.30	3.90	<.001	0.09 to 0.27	0.48	6.75	<.001	0.21 to 0.38
Fetal attachment (X)→ antepartum depression (M2)	–0.20	–2.46	.015	–0.15 to –0.01	–0.03	–0.34	.729	–0.09 to 0.06
Social support (M1) → antepartum depression (M2)	–0.04	–0.55	.577	–0.14 to 0.08	–0.31	–3.47	<.001	–0.35 to –0.09
Fetal attachment (X) → anxiety (Y)	–0.16	–2.81	.005	–0.23 to –0.04	–0.05	–0.74	.458	–0.15 to 0.06
Social support (M1) → anxiety (Y)	–0.11	–2.06	.040	–0.31 to –0.01	–0.22	–3.21	.001	–0.50 to –0.11
Antepartum depression (M2) → anxiety (Y)	0.66	11.86	<.001	1.10 to 1.54	0.58	9.26	<.001	0.85 to 1.32
Indirect effect
Total	–0.18			–0.31 to –0.06	–0.21			–0.35 to –0.08
Indirect 1: fetal attachment (X) → social support (M1) → anxiety (Y)	–0.03			–0.09 to 0.09	–0.11			–0.18 to –0.04
Indirect 2: fetal attachment (X) → antepartum depression (M2) → anxiety (Y)	–0.14			–0.26 to –0.01	–0.01			–0.13 to 0.09
Indirect 3: fetal attachment (X) → social support (M1) → antepartum depression (M2) → anxiety (Y)	–0.01			–0.04 to 0.02	–0.08			–0.14 to –0.03
Total effect
Fetal attachment (X) → anxiety (Y)	–0.28	–4.54	<.001	–0.41 to –0.16	–0.22	–3.36	<.001	–0.35 to –0.09

Table 1. Differences in anxiety according to subjects’ characteristics in high-risk pregnancy couples (N=294)

SD, standard deviation; KRW, Korean won.

Table 2. Differences in study variables between women and men who experienced high-risk pregnancy (N=294)

Values are presented as mean±standard deviation or number (%). The fetal attachment score for the woman in the pair, normalized to a 100-point scale.

EPDS, Edinburgh Postnatal Depression Scale.

Table 3. Relationships among fetal attachment, social support, antepartum depression, and anxiety in women and men who experienced high-risk pregnancy (N=294)

^a)Correlations assessed between males’ and females’ reports are shown in the blank diagonal (147 couples).

Table 4. Mediation effects of social support and antepartum depression in the relationship between fetal attachment and anxiety in women and men who experienced high-risk pregnancy (N=294)