Quality of life,depressive symptoms,suicidal behavior and social support among pregnant adolescents in Mexico

Abstract

Background

Suicidal behavior in adolescents is a public health problem. Although it has been reported that there is a link between suicidal behavior and Quality of life (QoL), this relationship has not been explored in pregnant adolescents, nor have depressive symptoms been examined as mediators and social support as a moderator in a moderated mediation model.

Methods

In 2021, 143 pregnant adolescents between 13 and 19 years old from different states in Mexico were evaluated. The KIDSCREEN-52 instrument was applied to evaluate the Health-Related Quality of Life, the scale of expectation of living and dying of Okasha, the Edinburgh Postpartum Depression Scale, the family and partner support scale (AFA-R) and sociodemographic information. Moderated mediation analyses were completed.

Results

A relationship between QoL and suicidal behavior was found, and that relationship was mediated by depressive symptoms on all eighteen models. In addition, social support from the family moderated the mediation of depressive symptoms in 4 of 9 QoL dimensions, and social support from the partner moderated the mediating effect of depressive symptoms in 8 of 9 QoL dimensions.

Conclusion

The relationship between QoL and suicidal behavior was consistent with previous studies. The moderating role of social support and the mediation of depressive symptoms on the relationship between QoL and suicidal behavior were also consistent with the literature. Professionals who work with pregnant adolescents should consider both depressive symptoms and social support as important factors that influence QoL and suicidal behaviors.

Keywords

subjective wellbeing depression suicide pregnant adolescent

Health-Related Quality of Life (HRQoL) refers to a multidimensional construct that includes physical, emotional, mental, social and behavioral aspects, taking into account how these aspects are perceived by the individuals.¹ During pregnancy, HRQoL may be affected, particularly among adolescent females^2,3 who may experience insecurity in the face of motherhood and suffer from school dropout, lack of social support, and stress due to the symptoms of pregnancy and childbirth.^4-6

Suicidal behavior is a multifactorial phenomenon that includes suicidal ideation, planning and attempt, as well as suicide.^7-9 Currently, the prevalence of suicidal behaviors in adult women is reported to be 3.4 to 22.6%^10-13 and 13.3% in pregnant adolescents worldwide.¹⁴ Some of the risk factors associated with suicidal behavior in pregnant adolescents are experiencing violence from their partner, having a low economic level, being rejected by their family, having chronic diseases, and being socially isolated.¹⁵

The main focus when studying suicidal behavior in pregnant women has been suicidal ideation. It is known that women with suicidal ideation have a higher probability of having a premature birth, losing the child; or having children with low birth weight and poor cognitive development.^16,17 Although studies on HRQoL and some of the constructs that belong to suicidal behavior have been found, it is important to indicate that no studies have been found in Mexico that address the relationship between HRQoL and suicidal behaviors in pregnant adolescents.

Depressive symptoms in adolescents can include irritability, sadness and various cognitive and somatic changes that affect their well-being.¹⁸ In pregnant adolescents, a prevalence of depressive symptoms of 29.2% has been found.^19,20 The risk factors associated with the presence of depressive symptoms during pregnancy in adolescents are having an unwanted pregnancy, being a victim of verbal, physical and/or sexual violence, receiving negative criticism from the family, having poor or no communication with the baby's father, lacking social support, having a history of child abuse and/or neglect, having poor access to health services, experiencing low self-esteem and having an anxious attachment.^21-27

A systematic review that considered women in the age range of 14 and 45 years determined that women with depressive symptoms during pregnancy may have difficulties breastfeeding, be concerned about their mental and physical state, decrease their interest in seeking to improve their health, have complications during childbirth, postpartum complications, heavy bleeding, abnormalities of the placenta, and seizures, among other negative consequences.²⁸ In 2017 Lara et al²⁹ reported that studies in Mexico on pregnancy and depression in pregnant women were limited. Currently, few have been added,^30,31 however, it has been reported that pregnant adolescents have emotional health difficulties that can lead to suicidal behavior during pregnancy,^32-34 and it has been suggested that social support during pregnancy is essential to reduce the risks of depressive symptoms.⁴

Social support is the availability of support obtained from family, colleagues or friends.³⁵ Current systematic reviews and meta-analyses have reported that a low level of social support can lead to emotional distress, such as self-harm, anxiety and depression.^36,37 In another sense, social support during pregnancy reduces depressive symptoms and improves QoL, and it has also been determined that adolescents generally receive more social support from family members -especially from their mothers-than from their partner.^4,38,39

In Mexico, it is estimated that there are 340,000 pregnancies a year in children under 19 years of age,⁴⁰ which is a concern, especially given the scant research on QoL, depressive symptoms and suicidal behaviors in Mexican adolescents who are pregnant. According to the literature, social support has a moderating effect on depressive symptoms and suicidal behavior.^41-43 While this finding is from studies of the general population, social support is important in the moderation of depressive symptoms and suicidal behavior among adolescents who are pregnant.

The study of indirect relationships between variables is important since in this way it is possible to understand the mechanisms that contribute to the occurrence of an effect. In this research it was taken into account that some studies had already explored the relationship between suicidal behavior and QoL, but none had been carried out in Mexico, in addition the role that depressive symptoms and social support could have in said relationship.

Specifically, no studies have been found where the variable depressive symptoms have been studied as a mediator between QoL and suicidal behaviors in adolescents who are pregnant. At the same time, there are no studies that have explored the moderating role of social support in the relationship between HRQoL, suicidal behavior and depressive symptoms in the pregnant population. Thus, there is a gap in the knowledge about the mechanisms that explain the relationship between suicidal behavior and HRQoL in adolescents who are pregnant.

The objective of this study was to determine whether there is a relationship between QoL and suicidal behavior, whether this relationship is mediated by depressive symptoms and/or moderated by social support among pregnant adolescents in Mexico (Figure 1).

Figure 1.

Moderated mediation model.

Method and design

Participants

The sample was non-probabilistic for convenience and consisted of 143 teenagers who were 13 and 19 years old. A total of 79.7% resided in the state of Coahuila, and the rest resided in other states of Mexico.

The inclusion criteria were as follows: being 13 to 19 years old and signing the informed consent form. The exclusion criterion was to have a diagnosis of some health disorder. Participants who did not answer 10% or more of the items of all the applied instruments were excluded from the study.

Instruments

The socioeconomic level was evaluated with the scale of the Mexican Association of Market Intelligence and Opinion Agencies⁴⁴ and an ad hoc questionnaire, which obtained sociodemographic variables such as academic level, marital status, substance use and number of children.

To evaluate QoL, the self-report questionnaire KIDSCREEN-52⁴⁵ was used, which is composed of 52 items that are grouped into 10 dimensions: physical well-being, psychological well-being, state of mind, self-perception, autonomy, relationship with and family life, friends and social support, school environment, social acceptance (bullying) and financial resources. Items are scored on a 5-point Likert scale ranging from low to high frequency (not at all, a little, moderately, frequently and very often) or from low to high intensity (never, almost never, sometimes, almost always and always). The results generate an overall rating from zero to 100. Since most of the study subjects were not in school (79.1%), the “school environment” dimension was eliminated, leaving 9 of the 10 dimensions for the analysis. The confirmatory factor analysis (CFA) for this sample with a bifactor model was adequate, and its goodness of fit indices were χ² (1250.29) = 94, P < .001), comparative fit index (CFI) = .97; Tucker‒Lewis index (TLI) = .97; root mean square error (RMSEA) = .05 (90% CI [.04.06]) and internal consistency of a Cronbach's alpha of .96 and an omega coefficient (ω) of .68.

To assess social support, the adaptation of the Family and Partner Social Support Scale (AFA-R) was used⁴⁶ it is a self-report scale with 14 items that are grouped into 2 dimensions: Family Social Support and Social Support of the Couple, with Likert-type response options ranging from never (1) to always (5). The CFA for this sample obtained adequate goodness of fit indices: χ2 (98.171) = 76, P = .044), CFI = .967, TLI = .960, RMSEA = .045 (90% CI = [.008-.069]) and internal consistency of an α of .93 and a ω of .97.

To evaluate depressive symptoms, the Edinburgh Postpartum Depression Scale⁴⁷ was used, which consists of 10 items with 4 response options that directly address the construct and 6 that indirectly address the construct. The CFA was performed with a bifactor model, and it had adequate goodness of fit indices: χ2 (53.497) = 34, P < .018), CFI = .955, TLI = .941, RMSEA = .064 (CI 90% = [.027-.095], internal consistency of ⍺ .912 and a total ω of .92. This article takes the cutoff point of 8/9 suggested for the adolescent population.⁴⁸

Finally, suicidal behavior was assessed through the Living and Dying Expectation Scale.⁴⁹ It is a one-dimensional scale with 4 questions: (1) Have you ever thought that life is not worth it? (2) Have you ever wished you were dead? (3) Have you ever thought about ending your life? (4) Have you attempted suicide? The first 3 items range from zero = never to 3 = many times, while the fourth item has response options ranging from zero = no attempt to 3 = 3 or more attempts. The total score of the sum ranges from zero to 12 points; the higher the score is, the more serious the suicidal behavior. The CFA was performed with a congeneric model, resulting in the following goodness of fit indices χ2 (1.503), P = .472), CFI = 1.00, TLI = 1.00, RMSEA = .000 [IC 90% .00-.153] internal consistency of ⍺ .98 and ω .95.

Procedures

The application of the instruments was carried out between January and November 2021 in 2 modalities due to COVID-19. The online applications began in January 2021, and after authorization from the hospitals, they were applied to the adolescents in person beginning in March during prenatal consultations in the gynecology service of 2 second-level hospitals in the municipalities of Torreón and Matamoros Coahuila. The project was approved by the Research Ethics Committee of the university in charge (CEI/016/2020) and was registered by the Ministry of Health, health jurisdiction VI 10/19/2020. All participants agreed to participate.

Data analysis

Frequencies of the sociodemographic variables, means and standard deviation of the variables under study were calculated. To evaluate the validity and reliability of the inferences of the variables under study, the X2 indices were obtained, expecting P < .05; CFI and TLI indices ≥.95;⁵⁰ RMSEA with its 90% confidence intervals expecting indices between .05 and .08,⁵¹ and alpha and omega were calculated, expecting a coefficient greater than.7. The previous analyses were carried out with R Studio (R Studio Inc., Boston, MA, USA). To test the moderated mediation model, path 15 was used, and the analysis of conditioned processes was performed, considering a 95% confidence interval based on 10,000 bootstrap samples. The standardized effects of the mediation models were analyzed, and the standardized beta, the indirect effect index as well as the standard error were obtained. The Index of partial moderated mediation was also obtained to the moderated mediation models. Mediation and moderation of mediation were assessed using confidence intervals. Mediation and moderation of the mediation were considered when the interval did not pass through 0. For this process, Hayes´Process macro for IBM SPSS 26 (SPSS Inc., Chicago, IL, USA) was used.

Results

Table 1 shows the sociodemographic data of the sample. The average age of the participants was 16.99, SD = 1.51. Most of them lived in a free union. A total of 76.03% had dropped out of their studies. Just over half of the participants (51.0%) lived with their parents, while 43.4% lived with their partner. According to the indices proposed by the Mexican Association of Market Intelligence and Opinion Agencies⁴⁴ the socioeconomic level with the highest frequency was D (25.2%); at this level, 86% of homes have 1 or 2 bedrooms, 48% of the expenses are allocated to food, and 53% the provider's educational level has reached elementary school.

Table 1.

Sociodemographic Data of Participating Pregnant Adolescents (N = 143).

Variable	n	%
Marital status
Free union	74	51.7
Single	32	22.4
Live with couple	26	18.2
Married	7	4.9
Separated	4	2.8
Living arrangements
With parents	73	51
Couple	62	43.4
Grandparents	3	2.1
Others	5	3.5
Socioeconomic level
E	2	1.4
D	36	25.2
D+	28	19.6
C-	30	21
C	30	21
C+	12	8.4
A/B	5	3.5

Notes. Most households have a head of household not older with studies up to primary school, the tendency of Internet in the household is minimal, most of the expenditures are allocated to food; D, there are 2 or more rooms in the household, 14% have Internet and 53% of the head of household has studies up to primary school; D+, 74% of households are headed by a head of household with studies up to secondary school, 55% of households have Internet and 42% allocate of their expenditures on food; C-, 63% of households are headed by a head with studies above secondary school, 68% of households with 1 or 2 bedrooms, 78% have Internet at home, 40% of expenditures are allocated to buying food and 18% to transportation; C, 82% of households have a head with a high school education or higher, 40% of households have at least 3 bedrooms, 91% have Internet, 37% of expenditures are used for food and 14% of households have at least 2 cars; C+, 72% of the households have a head of household with a high school education, 53% of the houses have 3 bedrooms, 30% have at least 2 cars, 97% of the houses have Internet, more than a third of the income is spent on food; A/B, have the head of household has professional or postgraduate studies, 72.5% of the homes have at least 3 bedrooms, 67% of the homes have at least 2 cars and almost all homes have Internet.

The mean age at which the adolescents left school was 15.21 years of age (SD = 2.1), and the age of onset of sexual life was on average 15.23 years (SD = 1.49). A total of 86.7% of the participants were primiparous, 60.8% had not planned the pregnancy, and 10.5% had considered interrupting it. The average age of the biological parent of the fetus was 20.16 years (SD = 4.4), with a range from 13 to 38 years.

Regarding depressive symptoms, 53.8% of the adolescents had symptoms of depression, and 23.7% of the adolescents showed suicidal behaviors.

In Table 2, the means and standard deviation of the scores of the study instruments are observed. In relation to social support, the average score of the couple was higher than the average score of the family. Regarding QoL, the highest score was for the dimension of relationship with family life, and the lowest score was for the dimension of physical well-being.

Table 2.

Descriptive Statistics of the Study Variables with Pregnant Adolescents (N = 143).

Variable	M	SD
Suicidal behavior	2.06	3.2
Depressive symptoms	9.3	7.13
Social support
Family social support	13.93	6.85
Couple social support	15.63	9.32
Quality of life
Physical well-being	34.89	5.79
Psychological well-being	44.58	10.66
Mood/Emotion	41.03	12.63
Self-perception	48.69	11.09
Autonomy	43.23	12.33
Parent relationship and home life	49.32	12.99
Social support and peers	37.2	12.37
Financial resources	41.01	8.04
Social acceptance (bullying)	44.24	11.23

Notes. M, media; SD, standard deviation.

The Spearman correlations shown in Table 3 are mostly significant and positive among depressive symptoms, suicidal behavior and the dimensions of HRQoL, in addition to moderate and strong negative correlations. On the other hand, moderately strong positive correlations are observed between family support and the rest of the variables compared to partner support.

Table 3.

Bivariate Correlations Between the Dimensions of Quality of Life, Suicidal Behaviors, Depressive Symptoms, Social Support From the Partner and Social Support From the Family.

Variables	1	2	3	4	5	6	7	8	9	10	11	12	13
1. Physical well-being	-
2. Psychological well-being	466**	-
3. Mood/Emotion	355**	.718**	-
4. Self-perception	362**	.645**	.686**	-
5. Autonomy	362**	.595**	.692**	.679**	-
6. Parent relationship and home life	391**	.687**	.587**	.631**	.603**	-
7. Social support and peers	232*	.517**	.522**	.498**	.573**	.500**	-
8. Social acceptance (bullying)	136	.346**	.546**	.493**	.457**	.393**	.246*	-
9. Financial resources	165	.454**	.498**	.438**	.515**	.476**	.523**	.353**	-
10. Suicidal behavior	−292**	−.611**	-.690**	−.558**	−.542**	−.556**	−.427**	−.390**	−.521**	-
11. Depressive symptoms	−348**	−.696**	−.854**	−.689**	−.668**	−.636**	−.479**	−.462**	−.453**	.703**	-
12. Couple social support	−.421**	−.549**	−.558**	−.511**	−.508**	−.483**	−.243**	−.311**	−.389**	.450**	−.572**	-
13. Family social support	−.421**	.597*	−.641**	−.632**	−.604**	−.797**	−.425**	−.387**	−.469**	.554**	.660**	.782**	-

Notes. ** Correlation was significant at the .01; * Correlation was significant at .05.

The indirect effect indexes and their confidence intervals for each of the dimensions were: physical well-being −.23 [−.41, −.05]; psychological well-being−.47 [−.62, −.33]; mood/emotion−.58 [−.74, −.42]; parent relationship and home life−.45 [−.58, −.34]; social support and peers-.33 [−.46, −.21]; social acceptance (bullying)−.36 [−.49, −.22]; self-perception−.52 [−.65, −.38]; autonomy-.49 [−.61, −.38] and financial resources−.34 [−.45, −.21].

Table 4 shows the standardized effects of the mediation models for depressive symptoms, suicidal behavior, and QoL dimensions. As seen in the confidence intervals, mediation was presented in all dimensions.

Table 4.

Standardized Effects of the Mediation Models of Depressive Symptoms, Suicidal Behavior, and Quality of Life Dimensions.

Model	β	SE	P	IEI [CI 95%]	SE
Physical well-being
a	−.37	.12	.00	−.23 [−.41, −.05]	.09
b	.37	.03	.00
c’	.00	.04	.98
c	−.14	.06	.02
Psychological well-being
a	−.46	.05	.00	−.47 [−.62, −.33]	.07
b	.33	.04	.00
c’	−.04	.03	.15
c	−.19	.03	.00
Mood/Emotion
a	−.49	.03	.00	−.58 [−.74, −.42]	.08
b	.35	.05	.00
c’	−.02	.03	.53
c	−.17	.02	.00
Self-perception
a	−.43	.05	.00	−.52 [−.65, −.38]	.07
b	.37	.04	.00
c’	−.16	.07	.87
c	−.16	.03	.00
Autonomy
a	−.38	.04	.00	−.49 [−.61, −.38]	.06
b	.36	.04	.00
c’	−.01	.02	.74
c	−.14	.02	.00
Parent relationship and home life
a	−.35	.04	.00	−.45 [−.58, −.34]	.06
b	.35	.04	.00
c’	−.02	.02	.25
c	−.14	.02	.00
Social support and peers
a	−.26	.05	.00	−.33 [−.46, −.21]	.07
b	.36	.03	.00
c’	−.01	.02	.58
c	−.10	.03	.00
Social acceptance (bullying)
a	−.30	.06	.00	−.36 [−.49, −.22]	.07
b	.37	.03	.00
c’	−.01	.02	.78
c	−.12	.03	.00
Financial resources
a	−.44	.08	.00	−.34 [−.45, −.21]	.06
b	.33	.03	.00
c’	−.09	.03	.00
c	−.23	.04	.00

Notes. β: Beta standardized; IEI, Indirect effect index; CI, Confidence interval; SE, Standard error; N = 143.

Table 5 shows 18 models of moderated mediation, 9 regarding the moderation of the social support of the family and another 9 of the moderation of the social support of the partner. Social support from the family moderated the mediation of depressive symptoms in 4 models, while social support from the partner moderated the mediation of 8 models.

Table 5.

Moderated Mediation Models of Family Support and Partner Support with the Dimensions of Quality of Life, Suicidal Behavior and Depressive Symptoms.

Measurement	Family social support			Couple social support
Measurement	Index	CI	SE	Index	CI	SE
Physical well-being	.04	−.0069, −.1319	.03	.04	−.0019, .1030	.02
Psychological well-being	.06	−.0007, .1262	.03	.04	.0024, .1011	.02
Mood/Emotion	.06	.0089, .1284	.03	.05	.0136, .1119	.02
Self-perception	.05	−.0026, .1150	.02	.05	.0034, .1052	.02
Autonomy	.05	−.0027, .1010	.02	.04	.0039, .0863	.02
Parent relationship	.04	.0013, .0965	.02	.03	0019, .0780	.01
Social support and peers	.03	−.0018, .0727	.01	.02	.0028, .0653	.01
Social acceptance (bullying)	.04	.0003, .0827	.02	.03	.0009, .0687	.01
Financial resources	.04	−.0204, .1188	.03	.05	.0053, .1178	.02

Notes. Index, Index of partial moderated mediation; SE, Standard error; CI, Confidence interval.

Discussion

Teen pregnancy can have negative consequences on lives (appointment). The objective of this study was to determine whether there is a relationship between QoL and suicidal behavior, whether this relationship is mediated by depressive symptoms and/or moderated by social support among pregnant adolescents in Mexico. It was found that the social support of the family moderated the mediation of depressive symptoms in the models that consider the dimensions of physical well-being, moods and emotions, parent relations and social rejection. It was also observed that the social support of the couple moderated the mediation of depressive symptoms between suicidal behavior and each of the dimensions of QoL except the model of the physical well-being dimension.

The relationship between the different dimensions of QoL and suicidal behavior was found, which coincides with what was found in the Goldney Study⁵² carried out in Australia, which examined the relationship between HRQoL and suicidal ideation in 3010 people aged 15 an over, finding that suicidal ideation is related to a low QoL in each dimension of the instruments used. It also agrees with the study of an adolescent population in Chile that examined the association between HRQoL with the EQ-5D-5L scale and the suicide risk of 128 adolescents between 15 and 19 years of age; these researchers observed that the greater the pain/discomfort in the state of health was, the greater the risk of suicidal behavior.⁵³ Two studies were carried out in Mexico that explored the association of suicide risk with QoL. The first study enrolled 899 students aged 14 to 18 years and used the Youth Quality of life Instrument- Research version (YQOL-R) instrument, suicidal risk behaviors increased in women from 2.8 to 7.6 times the possibility of a lower QoL.⁵⁴ In the second study, the HRQoL was examined with the KIDSCREEN-52 in 1229 students aged 14 to 18 years (M = 15.45, SD = .87); having low levels of support from parents, family and friends increases suicidal ideation, while suicidal planning is related to a low score on physical and psychological well-being tests, which indicates a relationship between the construct of suicidal behaviors and HRQoL.⁵⁵

The negative association between the dimensions of QoL and suicidal behavior found in this study coincides with the motivational-volitional theory of suicidal behavior, which states that such behavior is motivated both by poor functioning and by stressful events in the environment that are combined with and triggered by feelings of defeat, humiliation, betrayal, lack of support or painful feelings.⁵⁶

As expected, depressive symptoms mediated the direct relationship between QoL and suicidal behavior, considering the antecedents of 3 studies that found a relationship between depressive symptoms and suicidal ideation; 1 of these studies was conducted with 1285 Mexican adolescents aged 12 to 18 years.⁵⁷ A second was conducted in Puerto Rico with 179 adolescents from 13 to 18 years of age,⁵⁸ a third with a sample of 911 Mexican adolescents from 14 to 18 years of age.⁵⁹

Various studies have observed that there is a relationship between depressive symptoms and suicidal behaviors during pregnancy.^15,60,61 In Colombia and Brazil, depressive symptoms and suicidal behaviors were associated.^33,62,63 In the United States, with a sample of 294 adolescents, a relationship between depressive symptoms and suicidal ideation of 11% was found, with African-American adolescents being the most vulnerable population.⁶⁴

It is known that a high level of social support during pregnancy can be a protective factor in preventing depressive symptoms.^65,66 In our study, it was found that family social support moderated the mediation of depressive symptoms between suicidal behavior and QoL. These data coincide with those of a study of 449 pregnant adolescents in Thailand, which reported that family support is an important element in reducing depression.⁴ These same results were observed with 176 adolescents aged 15 to 18 in Nairobi, Kenya, in which the absence of family support was highlighted as a risk factor for depression.⁶⁷ In Portugal, the support of the mother had a direct dampening effect on depression.³⁹ Regarding the Latin American population, in Mexico, a total of 100 pregnant women (50 adolescents and 50 adult women) were studied. The authors of the research determined that those women who had support from their mother buffered the indirect effect of depressive symptoms between their perception that the pregnancy would have a negative effect on their lives and their quality of life.⁶⁸ These findings are important since they help to explain the importance of the support that adolescents perceive during pregnancy. This is particularly relevant to the present study, since there are few studies in Mexico that have examined the social support among pregnant teenagers.

We observed that the social support of the family moderated the mediation of depressive symptoms on the relationships of physical well-being, moods and emotions, parent relations and social rejection with suicidal behavior. In Pakistan, 120 women who were pregnant were studied. The objective of the research was to determine the relationship between social support and QoL and found that high social support (including family support) resulted in high scores in each dimension of QoL.⁶⁹ In the same way, in our study, partner social support moderated the mediation of depressive symptoms between suicidal behavior and each of the QoL dimensions except for the physical well-being dimension. The results presented coincide with the contributions of a systematic review, indicating that a high level of social support is positively correlated with emotional well-being.³⁶

At present, it is known that women who have difficulties managing finances, show depressive symptoms during pregnancy and are more likely to receive low social support.^37,66 In our study, we found that the social support of the family moderated the mediation of depressive symptoms on the relationship between the economic resources dimension of QoL and suicidal behavior. The results that we refer to contrast with another sample of 100 Mexican females between the ages of 13 and 18 who were pregnant, which found that lack of money is a factor in presenting symptoms of mild depression.⁶⁸ Likewise, these findings are contrary to those observed by Osok et al.⁶⁷ Who found that adolescents with incomes of more than $15,000 Kes (approximately $148.5 dollars) per month reported greater depression. A possible explanation for the diversity of the results can be explained by sociocultural differences, since the Osok et al sample lives in Kenya, or by family-type aspects, since the Martínez and Waysel samples reported that they had relatives who consume illicit substances.⁶⁸

Regarding the relationship between social support and suicidal behavior, evidence has been found about how the support perceived by adolescents moderates the relationship between depression and suicidal behaviors.⁴³ In pregnant adolescents in Brazil, high social support (aPR = .33, 95% CI, .19-.56) was a protective factor to prevent suicidal behaviors,¹⁴ while in Peru, pregnant adolescents who perceived support from some family members, partners, friends, religious groups and health personnel showed lower levels of suicidal ideation.⁷⁰ These results also coincide with a sample of pregnant adolescents in Bangladesh, in which the greater the social support from friends was, the less likely they were to attempt suicide (OR = .69, 95% CI, .55-.86).⁷¹ The previous results coincide with systematic reviews indicating a relationship between social support and depressive symptoms in women who are pregnant, and it has been precisely established that high social support can reduce depression in pregnant women.³⁶

A limitation of the study was the size of the sample. The pregnant adolescent population is vulnerable, which makes it difficult to access, both due to subjects’ ages and conditions. The pandemic also limited access to more people; however, the number of participants was sufficient for the analyses that were carried out. Although self-report questionnaires were administered, they are internationally recognized questionnaires, and the validity and reliability data for this sample were adequate. We observed that the adolescents who responded to the online instruments had higher means in each of the variables to be studied compared to the adolescents who responded in person. A possible explanation could be because the face-to-face sample came from a single state and sociocultural differences could be involved. Alternatively, it could be that the differences are due to the confinement generated by the COVID-19 pandemic since the sample evaluated online was confined and the face-to-face sample was not.

To the best of our knowledge, this is the first study in pregnant adolescents on the direct effect of QoL on suicidal behavior and the mediating effect of depressive symptoms and the moderating effect of social support.

Future research could continue to investigate the different types of support that adolescents receive, such as support from their peers, the support that adolescents who are still studying during pregnancy receive and even support from medical personnel. Similar studies could also be carried out with samples from different countries.

Footnotes

Acknowledgements

The main author would like to extend special thanks to Consejo Nacional de Ciencias, Humanidades y Tecnologías (CONAHCYT) by the scholarship 589539 for his Doctoral Degree in Psychology with orientation on Quality of Life and Health of the Unversity of Guadalajara.

Author contributions

ES contributed to the original design of the project, the collection of results, the analysis of data, and the writing and approval of the final manuscript; CH contributed to the original design of the project, data analysis, and writing and approval of the final manuscript; LN contributed to the original design of the project and the writing and approval of the final manuscript.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Center for Research of Risks and Quality of Life, University of Guadalajara. The main author would like to extend special thanks to Consejo Nacional de Ciencias, Humanidades y Tecnologías (CONAHCYT) by the scholarship 589539 for his Doctoral Degree in Psychology with orientation on Quality of Life and Health of the Unversity of Guadalajara.

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