Relationships among depression during pregnancy,social support and health locus of control among Iranian pregnant women

Abstract

Background:

Prenatal depression is a significant predictor of postpartum depression and is detrimental to fetal development.

Aim:

To examine whether depression during pregnancy is associated with social support and health locus of control (HLC).

Method:

Data were collected from a sample of 208 Iranian pregnant women using a demographic questionnaire, the Edinburgh Postnatal Depression Scale, the multidimensional HLC Scale and the social support appraisals.

Results:

Depression was experienced by 37% of participants. Overall, women reported higher level of family support (6.88 ± 1.15) than other supports (6.87 ± 1.29). Protective supports from other resources (6.87 ± 1.29) were higher than those from friends (5.94 ± 1.5). Internal, powerful others and chance beliefs had the highest mean scores. Social support and chance HLC significantly influenced the proposed mediator (depressive mood) in the linear regression model. Bivariate analysis showed significant associations between social support (friend, family and others) and depressive mood. Internal HLC had a significant association with social support and powerful others HLC. However, Pearson correlation coefficient was not significant between depressive mood and all dimensions of HLC.

Conclusion:

Clinicians could assess social support and chance HLC to identify and treat women at risk of prenatal depression. By providing support during pregnancy, depression levels in women and its effects on the fetus may be decreased, which could prevent postpartum depression.

Keywords

Pregnancy depression social support health locus of control

Introduction

During pregnancy, respect to the maternal role is vitally important to ensure the infant’s safety, survival and well-being, although it does not come without costs (Logsdon, Wisner, & Pinto-Foltz, 2006). In addition to the physical aspects, respect to social and psychological aspects is necessary (Tabrizi & Lorestani, 2011). Today, there is more emphasis on the study of individual mental health because mental disorders are chains that negatively affect individuals and their family functions, economic condition and public health. Mental illnesses are the secondary sources of disease resulting in economic problems (Mo & Mak, 2008), which have been shown to cause disability among women worldwide (Patel & Wisner, 2011). The peak prevalence of major depressive disorder in women is during the childbearing years. A recent population-based survey of more than 15,000 women found that the prevalence of major depressive disorder during pregnancy is 8.4%. Its prevalence is 1.5–3 times more in women (particularly in childbearing age) than in men (Patel & Wisner, 2011). The risk factors for depression during pregnancy are similar to those for postpartum depression. These include having a history of depression, anxiety, unintended pregnancy, family violence, stressful lifestyle, unsuitable socioeconomic status and lack of social support (Lancaster et al., 2010; Stewart, 2011). Because of less evidence to support an etiology or symptomatology, differentiating depressive symptoms during pregnancy from other life stages is difficult (Chaudron, 2013). In addition, the physical experiences of pregnancy, such as fatigue, sleep disruption, weight change and concentration difficulties, can overlap with the symptoms of depression and thus confuse the person investigating (Chaudron, 2013). Antenatal depression increases the risk of adverse outcomes, including preterm birth, pre-eclampsia, fetal growth restriction and infant behavior disorders (Grote et al., 2010; Yonkers et al., 2009). Depressed pregnant mothers are at risk of weight loss, drug abuse and neglect to maternal care. Untreated depression during pregnancy can result in a worse condition such as the thought of or attempting suicide. In addition, women with depression during pregnancy are at extra risk of postpartum depression, which may be a risk factor for the health and well-being of both mothers and infants. Thus, prevention, identification and treatment of perinatal depression are major public health priorities (Lisa et al., 2012). Social supports (such as family, friends, organizations and colleagues) have obviously been linked to positive health results. These supporters can provide several benefits for both the physical and the mental health of pregnant women (Copertaro et al., 2014). For example, prevalence of mortality because of diseases is lower among women receiving greater social supports (Stanton & Campbell, 2014). Social supports (family, friends, neighbors, colleagues and community members) make individuals feel that they are a member of a group in which one can share affection, aid and obligation (Lin et al., 2013). Research studies show that social supports are based on five dimensions: material support (financial assistance and provision of resources), emotional support (love, affection, respect and empathy), affective support (physical demonstrations of love and affection), positive interaction support (availability of people for fun and relaxation) and information support (guidance, advice and information; Yamashita, Amendola, Gaspar, Alvarenga, & Oliveira, 2013). Social support theory considers positive social support as a protective barrier against negative effects of depression on mental and physical health. Therefore, the lack of suitable social support may be a dangerous means for increasing depressive symptoms. Social support is similar to a tampon that reduces the stressful life events and helps patients in overcoming emotional tension (Nazik, Ozdemir, & Soydan, 2014). Finally, social support, as a social determinant of health, plays an important role in the promotion of psychosocial conditions in the lives of people (Setareh Forouzan et al., 2013). According to Basinska and Andruszkiewicz (2012), every person has specific ideas and beliefs, which are essential elements to take decisions such as those about his or her health. For the promotion of personal attitude about one’s health behaviors, the health locus of control (HLC) is an essential method for a healthy life environment. This theory attempts to make persons believe that their health is related to their own behavior (internal health locus of control (IHLC)) or to some external consequences (external health locus of control (EHLC); Luszczynska & Schwarzer, 2005). Some subsequent forms of EHLC are powerful others health locus of control (PHLC) and chance health locus of control (CHLC). Individuals with IHLC are more successful in protecting their health and in recovery and rehabilitation after diseases than others. In fact, the belief in IHLC is an active and intelligent way of overcoming stress, and it is also a positive psychological and physical adaptor during illness. In contrast, individuals with EHLC are more prone to passive behaviors during problems and illnesses. In general, PHLC and CHLC are external stimuli in persons with chronic illnesses and negative emotions such as depression, hostility, anxiety and physical disorders (Basinska & Andruszkiewicz, 2012).

Dibaba et al. (2013) showed that women who reported moderate and high social support during pregnancy were significantly less likely to report depressive symptoms. Elsenbruch et al. (2007) also reported that the lack of social support constitutes an important risk factor for maternal well-being during pregnancy and has adverse effects on pregnancy outcomes. Gabry (2005) suggested that the locus of control may be related to prenatal depression. Another study found that the external locus of control (ELOC-chance) was a statistically significant predictor of prenatal depression (Richardson, Field, Newton, & Bendell, 2012). Due to the lack of standardized practices and policies in the healthcare system, new mothers experiencing symptoms of depression could be lost for follow-up, and without appropriate intervention, these women may remain in a state of untreated depression for years, thus affecting their own health as well as the health of their partners and children (Abraham, 2008). Therefore, this study attempts to examine the associations between social support, HLC and depressive symptoms among pregnant women in Iran.

Method

Procedures and participants

This cross-sectional study was conducted on a sample of 208 pregnant women in 2013 in Gonabad, Iran. The inclusion criteria were as follows: to be pregnant for 26 weeks or more, without clinical and obstetric complications, with no past or present history of depression, literate (ability to read and write), with a healthy fetus on ultrasound and psychiatric treatment. The exclusion criteria were preterm delivery during intervention, history of hospitalization or stillbirth, serious physical and mental problems such as death of a first-degree relative during intervention and subject’s disinclination to continue the study.

Permission to collect data was obtained from the Research Ethics Committee of University of Medical Sciences, Iran. Women waiting for prenatal medical appointments at the healthcare offices were recruited using random selection method. Most of the pregnant women participated in the study and accepted the initial invitation. Few of them (2%–3%) refused, citing lack of time or interest in the research topic. The participants filled in the questionnaires before the medical appointment.

Questionnaires

A socio-demographic questionnaire was used to collect data regarding the pregnant women, which included age, education, financial status, child’s gender, planned or unplanned pregnancy of mothers, number of previous pregnancies, number of living children and gestational age at the time of research.

Edinburgh Postnatal Depression Scale (EPDS): EPDS is a screening tool used to detect prenatal and postnatal depression. This is a 10-item self-reporting questionnaire with four possible responses. The response categories are scored 0, 1, 2 and 3 according to increasing severity of symptoms; items 3 and 5–10 are reverse scored (i.e. 3, 2, 1 and 0; Husain et al., 2012). Scores less than 12 are considered non-depressed and 12 and above are considered depressed. Validity and reliability of the questionnaires have been confirmed according to other standardized questionnaires in Iran. Cronbach’s α coefficient and test–retest reliability were found to be .86 and .80, respectively (Montazeri, Torkan, & Omidvari, 2007).

Multidimensional Health Locus of Control Scale (MHLCS): The HLC questionnaire was administered in order to examine the extent to which centenarians believed that they had control over their health (IHLC) or if it was primarily due to fate (CHLC) or other people’s influence (PHLC; Tigani, Artemiadis, Alexopoulos, Chrousos, & Darviri, 2011). In this study, Form B comprising 18 items in three components (6 items each) was used. All items contained 6-point Likert style, scoring 1–6 marks, so that a person’s score could vary from 6 to 36 for each component, and they will not be summed up together, but calculated independently. There is no cut-off point in this tool, and the mean score is used for final evaluation (Wallston, 2005). A total of 496 university students participated in this study (Moshki & Ghofranipour, 2011). The reliability coefficients were calculated in two different methods: test–retest, parallel tests and Cronbach’s α. In order to assess the validity of the scale, Moshki used three methods including content validity, concurrent validity and construct validity. The corresponding validity scores of the questionnaire, as measured by Levenson’s IPC scale, were .57 (p < .001), .51 (p < .01) and .53 (p < .01) for IPC.

Social support appraisals

The social support appraisal (SS-A) scale is a 23-item instrument designed to assess the number of individuals believing that he or she is loved by, esteemed by, and engaged with family, friends and other people. The SS-A utilizes a combination of 18 positively worded items (e.g. my friends respect me) and five negatively worded items (e.g. I can’t rely on my family for support). Computed four scores included SS-A total (sum of all 23 items), SS-A family (sum of 8 ‘family’ items), SS-A friends (sum of 7 ‘friend’ items) and SS-A others (sum of 8 items referring to ‘people’ or ‘others’ in a general way). Previous studies have demonstrated that the SS-A is a valid measure of appraisals of social support. It has also been demonstrated to be reliable. Wilcox et al. (2010), for instance, reported internal consistency coefficients ranging from .81 (SS-A family) to .89 (SS-A total) (Wilcox et al., 2010). Ebrahimi Ghavam (1991) used five student samples and five social minority groups to determine the traceability and accuracy factors. The final evaluation of social support scale and the sub-scales of family and friends showed good internal stability between the samples. Cronbach’s α values for these scales were .90, .80 and .84 among the five student samples and .90, .81 and .94 among the five social minority groups, respectively. Correlation of family and friend sub-scales in both student groups was .51 and that for the minority social groups for each sub-scale was .52. For Iranian university students, sampling repeatability factors for sub-scales of family, friends and others were .55, .63 and .54, respectively. The internal stability factor for overall social support for Iranian university student samples was .90. The internal stability factor for overall social support for samples of Iranian high school students was .70. For high school students, repeatability factors for sub-scales of family, friends and others were .50, .50 and .60, respectively. Correlation between repeating of the entire scale after 6 weeks was −.81. The repeatability factors and retesting of sub-scales of family, friends and others were .84, .72 and .51, respectively.

Data analysis

Statistical analysis was performed using SPSS-21 software. Data analysis included descriptive statistics, linear regression and correlation coefficients. Before data analysis, the data were examined for normal distributions. Continuous data were normally or near-normally distributed. The total score of the EPDS was used as the dependent variable, and all other scores of the measures were independent variables. Total scores on each of the measures that yielded continuous data were compared using correlation coefficients so that the relationship of depression with the other continuous variables could be assessed.

Results

The prevalence of depression was found to be 37%. The mean age of the study participants was 27.5 years (SD = 5.2). The remaining demographic data are reported in Table 1.

Table 1.

Characteristics of the sample (categorical variables; N = 208).

	N	%
Age pregnant (weeks)
26–28	76	36.53
29–32	72	34.61
33–37	57	27.40
Planned pregnancy
Yes	175	84.1
No	31	19.9
Education
Primary	7	3.4
Secondary	11	5.3
Diploma	105	50.5
Higher	83	39.9
Abortion
Yes	34	16.3
No	172	82.7
No. of pregnancies
1	100	48.1
2	66	31.7
3	33	15.9
>3	8	3.35
Sex of fetus
Male	95	45.7
Female	71	34.1
Financial status
Very high	2	1.0
High	66	31.7
Moderate	133	63.9
Low	5	2.4
Very low	0	0

Overall, women reported higher level of family support than other supports. They also received greater support from others than from friends. As shown in Table 2, IHLC, PHLC and CHLC had the highest mean scores.

Table 2.

Range of score and mean values (SD) for Edinburgh, dimensions of social support and HLC.

	N	Minimum	Maximum	Mean	SD
Edinburgh	207	0	22	10.48	4.167
Friend	205	0	7	5.94	1.500
Family	205	3	8	6.88	1.153
Others	205	3	8	6.87	1.296
Social	205	9	23	19.70	3.286
Internal	207	14	35	28.30	3.548
Powerful	207	13	36	25.35	4.641
Chance	207	6	33	17.32	4.793

SD: standard deviation; HLC: health locus of control.

Table 3 shows the variables that remained in the final regression model using the stepwise method. The predictor variables (social support and CHLC) significantly influenced the depressive mood as shown by the linear regression model.

Table 3.

Hierarchical multiple regression analysis for variables predicting prenatal depression.

Model	B	SE	Beta	t	Sig.	R ²
1 Social	−.386	.085	−.303	−4.535	.000	.09
2 Social	−.392	.084	−.308	−4.646	.000	.11
Chance	.130	.058	.148	2.235	.027

The bivariate analysis showed significant associations between social support and depressive mood (p < .05). IHLC had significant association with social support (p < .01) and PHLC (p < .05). In addition, statistically significant relationship was found between PHLC and friend support (p < .05). These results are indicative of a significant correlation between IHLC and CHLC with PHLC. However, Pearson correlation coefficient was not significant between depressive mood and all dimensions of HLC (Table 4).

Table 4.

Correlation matrix for prenatal depression and major variables.

	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
(1) Edinburgh	1
(2) Friend	−.223**	1
(3) Family	−.225**	.415**	1
(4) Others	−.272**	.596**	.518**	1
(5) Social	−.303**	.846**	.748**	.849**	1
(6) Internal	−.013	.139*	.172*	.118	.179*	1
(7) Powerful	.006	.198**	.179*	.078	.186**	.307**	1
(8) Chance	.130	−.004	.025	.051	.031	.072	.383**	1

p < .05, **p < .01.

Discussion

Pregnancy is a natural phenomenon. Unfortunately, it is also associated with potential risks that threaten the lives of both mother and infant, even in technologically advanced countries. Maternal and infant mortality is associated with prenatal and childbirth complications that result from preventable as well as unpreventable causes. Many of these complications can be identified early and prevented if the pregnant women receive appropriate prenatal care by allowing them to interact with professionals who can counsel them about high-risk behaviors (Gabry, 2005). Social support is a vital resource for pregnant women and has a positive impact on their responses to pregnancy. During pressure events, social support has many psychological and physiological benefits for individuals, and various studies have documented an inverse relationship between high social support and depression (Parsai Rad, Amir Ali Akbari, & Mashak, 2011), which confirms our results, wherein a statistically significant correlation was observed between social support and depression during pregnancy. In this context, Elsenbruch et al. (2007) assessed the effect of social support on maternal depressive symptoms during pregnancy and the quality of life in the first trimester of pregnancy. They found that pregnant women with less social support reported more depressive symptoms and decreased quality of life. The authors concluded that lack of social support was a significant risk factor for maternal security during pregnancy and has adverse effects on pregnancy outcomes. In a descriptive correlation study of 101 low-income pregnant women in the last trimester of pregnancy, Gabry (2005) observed that social support from the woman’s partner was related to increased prenatal care attendance and social support from people other than the partner was related to positive health behaviors. Social support during pregnancy was examined in a prospective study of 129 high-risk, economically disadvantaged pregnant women in Los Angeles. The researchers examined the effects of prenatal social support on birth outcomes such as birth weight, Apgar scores, labor progress and maternal postpartum depression. Results showed that women with higher perceived support had babies with higher birth weights and Apgar scores, as well as a decreased incidence of postpartum depression (Collins, Schetter, Lobel, & Scrimshaw, 1993). This study supports the notion that improved interpersonal social support can promote infant and maternal health. Chaaya showed that social support of people around during pregnancy and after childbirth is important for women. In fact, the value that people around especially husbands give to pregnant women will give them hope and thus more time for a sense of peace and comparing their experiences with other women and enjoying this experience. These supports will lead to maternal positive attitude toward aspects of baby’s birth and will decrease the possible effects of hormonal and biological changes on their mental state (Aghapoor & Mohammadi, 2009). In this regard, Lu (1997) believes that social support will moderate the effects of stressful events and lead to the experience of positive emotions and that there is a positive relationship between social support and happiness and mental health.

Findings of this study revealed that the most perceived social support was related to pregnant women families as shown by the significant correlation between support from family members and depression during pregnancy. However, some studies did not show a significant relationship between support from family members and depression during pregnancy (Abdollahzade Rafi, Hassanzadeh Avval, Ahmadi, Taheri, & Hosseini, 2012; Greenglass & Noguchi, 1996). People who have more social support are less vulnerable to diseases even if they experience new stresses. Abnormal thinking and behaviors are more common among individuals who have less social support in the family (Abdollahzade Rafi et al., 2012). Chaaya and Boyd et al. believe that there is a relationship between social support, stressful life events, chronic diseases and depression in pregnant women, and this is an emphasis on the importance of psychological and social support during pregnancy. Thus, social support is considered as the strongest coping power for a successful and easy encounter with stressful events (including pregnancy) and it facilitates patients’ tolerance (Wilcox et al., 2010).

This study highlighted the highest mean score among pregnant women related to internal belief, powerful others belief and chance belief, which concurs with the results obtained by Richardson et al. (2012). Abraham (2008) also reported that internal, chance and powerful others beliefs had the highest mean scores. Chen, Acton and Shao (2010) also revealed that powerful others, internal and chance beliefs had the highest mean scores.

This study demonstrates that social support and ELOC (chance) are significant predictors of depressive symptoms specifically in pregnant women. These results are consistent with a previous research associating the locus of control with depression (Benassi et al., 1988). In addition, Richardson et al. (2012) showed that CHLC is an important predictor of depression. A moderate relationship was found to support the hypothesis that women with a decreased risk of postpartum depression will identify an internal locus of control (Abraham, 2008). These findings demonstrate that HLC is related to depressive symptoms, and the different dimensions of HLC have various impacts on the ability to predict depressive symptoms. These results also build upon a body of the literature indicating that the ELOC-chance factor may be a better predictor of depressive symptoms (Lamanna, 2000). A primary goal of this study was to determine the predictive validity locus of control scores for predicting depressive symptoms during the prenatal period.

This study showed no significant correlation between the internal, PHLC and depressive symptoms. In contrast, Abraham (2008) and Lamanna (2000) showed a significant negative relationship between IHLC and depression, and IHLC was significantly related to nutrition maintenance, health supervision, knowledge seeking about pregnancy and maintenance of social interaction. In another study in Iran, Moshki, Baloochi Beydokhti, and Cheravi (2014) showed a significant negative relationship between IHLC and postpartum depression. An earlier study by Labs (1986) examining the relationship between locus of control and related behaviors suggests that individuals with an internal perspective tend to engage in more health-promoting behaviors than do those with an external perspective. It was found that pregnant women with internal control perspectives tended to abstain from tobacco, caffeine and alcohol consumption and attended childbirth education classes more often than those with external perspectives (Labs, 1986). In addition, Lewallen (1989) found that pregnant women who had higher IHLC reported practicing healthier behaviors related to alcohol and tobacco use, exercise, nutrition, safety and stress management, whereas pregnant women who had higher score on EHLC and CHLC reported fewer healthy behaviors in these areas. Conversely, Lewallen (1989) found no significant relationship between a ‘powerful others’ perspective and women’s health behaviors. The findings demonstrated that there was a statistically significant correlation between PHLC and CHLC. However, Moshki, Tavakolizadeh, and Bahri (2010) while assessing the relationship between health control and lifestyle of pregnant women demonstrated no significant correlation between powerful others and chance beliefs.

Limitations and suggestions

First, this was a cross-sectional study; thus, the observed association cannot be interpreted as causal inferences. Perhaps the most obvious limitation of this study is that the study sample comprised only urban women, restricting its generalizability to a larger population of pregnant women. In addition, women were assessed only once during their pregnancy, ranging between the 26 and 36 gestational weeks. Longitudinal design and multiple assessments of pregnant women may provide an insight into how women’s thoughts about personal control change. Longitudinal assessment may also allow researchers to better identify the periods of pregnancy that are considered high risk of developing depressive symptoms. Lack of studies in this part was a limitation in our research. Another limitation is self-reported measures.

Nevertheless, the results can have several benefits for clinical practice. Perhaps the greatest benefit from this research is suggestion of more assessments for identifying high-risk persons exposed to developing depressive symptoms. Because social support and CHLC were significant predictors of depressive symptoms, clinicians could assess social support and CHLC scores to identify those women at risk of developing depression during their pregnancy and to develop prevention and treatment plans. Hence, by implementation of intervening measurements during pregnancy, depression and its effects on the fetus and neonate can be decreased among women, which in turn could prevent postpartum depression.

Conclusion

Social support influences depressive mood. Social support as a social determinant of health has an important role in improving psychosocial adjustment and well-being in people’s lives. Knowledge of social support in different groups of society, especially pregnant women, is important. However, there was no significant relationship between depressive mood and all dimensions of HLC. In addition, results indicate that social support and CHLC were the most obvious predictors of depressive symptoms.

Footnotes

Acknowledgements

The authors would like to thank the officials at the Social Development & Health Promotion Research Center, Gonabad University of Medical Sciences, Iran, for supporting the research. We are indebted to all pregnant women attending the healthcare centers of Gonabad city who participated in the study voluntarily.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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