Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Predictors of emotional distress in pregnant

women: the mediating role of relationship
intimacy

Eleonora C. V. Costa, Eva Castanheira, Litícia Moreira, Paulo Correia, Duarte

Ribeiro & M. Graça Pereira

To cite this article: Eleonora C. V. Costa, Eva Castanheira, Litícia Moreira, Paulo
Correia, Duarte Ribeiro & M. Graça Pereira (2017): Predictors of emotional distress in
pregnant women: the mediating role of relationship intimacy, Journal of Mental Health, DOI:
10.1080/09638237.2017.1417545

To link to this article: https://doi.org/10.1080/09638237.2017.1417545

Published online: 15 Dec 2017.

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 http://tandfonline.com/ijmh
ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 1–9

ß 2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2017.1417545

ORIGINAL ARTICLE

Predictors of emotional distress in pregnant women: the mediating role

of relationship intimacy
Eleonora C. V. Costa1,2 , Eva Castanheira3, Litı́cia Moreira2, Paulo Correia1, Duarte Ribeiro1, and M. Graça Pereira3
1
North Regional Health Administration, ACES Cávado III – Barcelos/Esposende, Barcelos, Portugal, 2Department of Psychology, Portuguese Catholic
University, Braga, Portugal, and 3School of Psychology, Applied Psychology Department, University of Minho, Braga, Portugal

Abstract Keywords
Background: Assessment and treatment of emotional distress during pregnancy show that Pregnancy, emotional distress, worries during
worries during pregnancy and interpersonal relationships with partners are the important pregnancy, relationship intimacy, marital
Downloaded by [193.126.83.109] at 02:30 28 December 2017

factors determining psychological health. satisfaction

Aims: The present study aimed to investigate the impact of worries during pregnancy,
relationship intimacy, and marital satisfaction on anxiety, depression, and stress symptoms in History
pregnant women, as well as to analyse the mediating effect of relationship intimacy between
marital satisfaction and emotional distress. Received 28 November 2016
Method: During their second and third trimester of pregnancy, 200 Portuguese women were Revised 12 June 2017
recruited during childbirth preparation consultations and completed the Cambridge Worry Accepted 9 November 2017
Scale (CWS), the Personal Assessment of Intimacy in Relationships Scale (PAIR), the Marital Life Published online 15 December 2017
Areas Satisfaction Evaluation Scale (MLASES), and the Depression, Anxiety, and Stress Scale
(DASS-21).
Results: Hierarchical multiple regression analyses showed that being unemployed or on sick
leave, being younger, having a history of miscarriage, having more worries during pregnancy,
and declaring low-relationship intimacy were the main predictors of emotional distress.
Relationship intimacy mediated the relation of marital satisfaction to anxiety and depression
symptoms.
Conclusions: This study highlights the importance of the worries during pregnancy and
relationship intimacy in shaping pregnant women’s emotional distress, and identifies both as
targets of intervention.

Introduction problems during pregnancy increase the risk of birth compli-

cations, preterm birth, and maternal postpartum depression,
Little research has been carried on the emotional distress
and may also affect foetus/infant development and the
profile of low-income pregnant women, the majority of
formation of a healthy bond between the mother and her
Portuguese population available in public primary care
new-born (Guardino & Schetter, 2014; Misund et al., 2014).
settings, despite such knowledge being likely to help devise
A range of demographic, obstetric, and psychosocial
better interventions to foster these mothers’ pregnancies,
factors may influence pregnant women’s psychological
benefiting also the newborn. About 10% of pregnant women
health. Studies on risk factors for emotional distress have
worldwide suffer from mental illness (women who fulfill
shown mental health problems during pregnancy to be
diagnostic criteria for depression and anxiety disorders),
associated with demographic factors like young maternal
especially from depression and anxiety (World Health
age (Melville et al., 2010), low educational level (Gourounti
Organization [WHO], 2008; WHO, 2014). Previous studies
et al., 2014), single status, high life stress (Lancaster et al.,
on pregnant women’s mental health have examined specific
2010), low annual income/unemployment, financial hardship
aspects like depression and anxiety and broader ones like
(Gourounti et al., 2013; Guszkowska et al., 2014), obstetric
emotional distress (Faisal-Cury et al., 2010; Staneva et al.,
factors like previous pregnancies and miscarriages (Gourounti
2016). Assessment of maternal emotional distress during
et al., 2013), unintended pregnancies (Lancaster et al., 2010),
pregnancy and the identification of risk factors are important
mental health problems, personal and relationship factors
for prevention and intervention purposes, since mental health
such as poor relationship satisfaction (Røsand et al., 2011),
and low or absent support from partners, extended family, and
Address where the work was carried out: Portuguese North Regional friends (Lancaster et al., 2010).
Health Administration, Ministry of Health.
Although the aforementioned risk factors for emotional
Correspondence: Eleonora C. V. Costa, Universidade Católica
Portuguesa, Praça da Faculdade, 1, Braga 4710-297, Portugal. E-mail:
distress have been investigated, it is noteworthy that inves-
eleonora@braga.ucp.pt tigation of the association between worries during pregnancy,
 2 E. C. V. Costa et al.
relationship intimacy, marital satisfaction, and antenatal
emotional distress is a relatively under-researched area.
Becoming a mother is an important life event and although
most women see pregnancy as a positive experience, worries
and concerns increase during pregnancy. In fact, worries
during pregnancy, i.e. concerns (worries content) about the
health of the baby and additional concurrent worries, both
general and pregnancy-related, also impact maternal emo-
tional functioning. These worries can be anticipatory (before
giving birth, e.g. going to hospital), concurrent with other
general worries (e.g. financial matters), and post-partum
(after giving birth, e.g. worries about the baby’s health and
development) (Peñacoba-Puente et al., 2011; Petersen et al.,
2009). Studies have found that emotional distress during
pregnancy (women who have depression and anxiety symp-
toms but not necessarily fulfil diagnostic criteria for those
disorders) is positively related to worries during pregnancy
(Gourounti et al., 2011; Petersen et al., 2009). For example,
Petersen et al. (2009) found that the total Cambridge Worry
Scale scores were strongly associated with stress, anxiety, and
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other negative mood outcomes among pregnant women.
Other studies showed that major worries were related to
pregnancy outcomes such as baby’s health, giving birth,
miscarriage, and financial matters (Gourounti et al., 2011;
Peñacoba-Puente et al., 2011). Also, preparing for the new
baby, going to hospital, and worrying about entering labor too
early are common (Petersen et al., 2009). Particularly, anxiety
disorders and stress have been associated with pre-partum
worries (Szabó, 2011).
The diathesis–stress model attempts to explain how genetic
or biological factors interact with stress from life experiences,
which may result in the development of a disorder (e.g.
depression, anxiety) or condition (Goforth et al., 2011).
According to the model, an individual’s biological vulner-
abilities, or predispositions, to particular psychological dis-
orders can be triggered by stressful life events. If on the one
hand the worries experienced during pregnancy predispose
women to the development of psychological distress, on the
other hand relationship factors such as marital satisfaction and
relationship intimacy are protective. Indeed, relationship
satisfaction and related aspects of relationship quality such
as intimacy are themselves robust predictors of pregnant
women’s mental health (Stapleton et al., 2012; Whisman
et al., 2011). Several studies showed a negative association
between marital satisfaction and psychological distress during
pregnancy (Røsand et al., 2011, 2012; Whisman et al., 2011).
For example, Gourounti et al. (2014) found that low marital
satisfaction was associated with anxiety in pregnant women.
Additionally, dissatisfaction with the partner relationship is a
significant predictor of maternal emotional distress (Røsand
et al., 2011) and is associated with emotional distress during
pregnancy, with good partner relationship moderating adverse
effects of various types of emotional strain (Røsand et al.,
2012). A study by Røsand et al. (2011) demonstrated a strong
negative relationship between self-reported relationship sat-
isfaction and emotional distress in pregnant women, showing
a buffering effect of relationship satisfaction on the effects of
some risk factors, according to the buffering hypothesis
(Farmer & Sundberg, 2010). From a prevention perspective, it
is important to explore possible protective factors, as well as
J Ment Health, Early Online: 1–9
risk factors, of emotional distress in pregnancy. It has been
documented that marital satisfaction and relationship intim-
acy are important protective factors regarding the individual’s
ability to handle stressful events and recovery after such
events. Therefore, variables such as pregnancy worries and
relationship factors (e.g. relationship intimacy and marital
satisfaction) may be considered determinants of emotional
distress and may also be considered as risk and protective
factors, respectively, that may explain individual differences
in psychological status during pregnancy. Consequently, it
would be worthwhile to evaluate pregnancy worries and
relationship variables in relation to antenatal emotional
distress.
Regarding relationship variables, relationship intimacy is
also negatively associated with emotional distress in preg-
nancy (Malary et al., 2015). Intimacy is the experience of
feeling close to and cared for by a partner with regard to a
specific experience. The relationship intimacy model was
developed in the context of a chronic disease (Manne & Badr,
2008) but we believe it may also be helpful regarding the
couple’s adaptation to pregnancy since the latter impacts the
couple’s relationship and benefits from a dyadic-level
approach. In fact, the model considers the marital relationship
as a resource and emphasizes the importance of intervening in
the relationship, specifically in communication behaviors in
order to maintain or improve the relationship in times of
stress, such as during pregnancy. Additionally, the model
suggests that women and their partners use behaviors that can
help or weaken the level of intimacy of the relationship, and
that women and their partners’ psychological adaptation to
pregnancy is determined by the intimacy of the marital
relationship. Although a growing body of literature has been
focusing on relationship processes, the mediating role of
relationship intimacy in the association between marital
satisfaction and psychological distress has been less studied.
The findings from the body of research indicate that
demographic/obstetric factors, individual factors, and rela-
tionship factors have a combined influence on emotional
distress in pregnant women, but the extent to which they
contribute to emotional distress is less clear.
This study investigated the influence of worries during
pregnancy, relationship intimacy, and marital satisfaction on
anxiety, depression, and stress symptoms in pregnant women,
after controlling for demographic and obstetric variables, and
assessed if relationship intimacy mediates the association
between marital satisfaction and emotional distress.
Methods
Sample and data collection
Pregnant women (N ¼ 200) were recruited in primary care
settings in Northern Portugal as they received childbirth
preparation. Potentially eligible participants were identified
by nurses through a small inquiry and approached by the
research psychologist. The eligibility criteria was to be
pregnant, to be seeking childbirth preparation consultation,
and to have basic writing and reading skills. Childbirth
preparation consultation is part of the program of childbirth
preparation/parenting, consisting of theoretical–practical ses-
sions and covers the following topics: labor and delivery,
 DOI: 10.1080/09638237.2017.1417545
labor analgesia, care of the newborn and breastfeeding, and it
enables the father to be involved in the birth in order to
minimise the anxiety on the part of the couple and increases
self-confidence. Women were excluded from the sample if
they had a risk pregnancy, a pathology or a psychopathology,
and/or an understanding of Portuguese insufficient for them to
give informed consent. Eligibility rate among all pregnancies
during the recruitment period was 96%. The recruitment
yielded 200 eligible women (M ¼ 31 weeks gestation) all of
whom agreed to participate in the study. Informed consent
was written and signed by all participants. After giving
informed consent, participants completed the measures in a
private room after the childbirth preparation class on the same
day of the recruitment. Data collection took approximately
30 minutes and participants were not paid. The study received
ethics approval from the Portuguese North Regional Health
Administration.
Measures
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Basic demographic and medical information included: age,
marital status, duration of marital status, educational level,
yearly income, work status, gestational age (weeks), parity,
pregnancy planning, complications during pregnancy, and
miscarriages.
Personal Assessment of Intimacy in Relationships Scale
(PAIR) (Schaefer & Olson, 1981) is a 36-item measure of
relationship intimacy in a 5-point (0 ¼ strongly disagree to,
4 ¼ strongly agree) Likert scale. Scores range from 0 to 144.
Higher scores indicate higher levels of relationship intimacy.
The measure includes five subscales: emotional intimacy,
social intimacy, sexual intimacy, intellectual intimacy, and
recreational intimacy. In the present study, we used the total
score of the scale as a measure of relationship intimacy. The
PAIR has been adapted to Portuguese and has been found to
have satisfactory psychometric properties (Moreira et al.,
2009). In the current sample, internal consistency for the total
instrument was 0.91.
Marital Life Areas Satisfaction Evaluation Scale
(MLASES) (Narciso & Costa, 1996) is a 44-item scale used
as a measure of perceived satisfaction with married life in a 6-
point (1 ¼ not at all satisfied to, 6 ¼ totally satisfied) Likert
scale. Scores range from 1 to 6. Higher scores indicate higher
perception of marital satisfaction. In the current sample,
internal consistency was 0.97, measured through the
Cronbach’s alpha.
Cambridge Worry Scale (CWS) (Green et al., 2003) has
16 items that assess the content and intensity of the
concerns experienced during pregnancy. The measure
includes five subscales: socio-medical area, relationships,
reproductive loss, health, and socio-economic area, rated on
a 6-point Likert scale (0 ¼ it is not a worry to, 5 ¼ is a big
worry). Scores range from 0 to 5. Higher scores indicate
higher number and greater intensity of worries. In the
present study, we used the total score of the scale as a
measure of intensity of worries during pregnancy. The
CWS has been adapted to Portuguese and has been found
to have satisfactory psychometric properties (Nazaré et al.,
2012). In the current sample, internal consistency was
adequate ( ¼ 0.86).
Emotional distress in pregnant women 3
Depression, Anxiety, and Stress Scale – 21 items (DASS-
21) (Lovibond & Lovibond, 1995) is a set of three self-report
scales designed to measure the emotional states of depression,
anxiety, and stress, in a 4-point (0–3) Likert scale. Each scale
contains seven items and scores for each scale range from 0 to
42 (final score of each scale is multiplied by 2). Higher scores
indicate higher intensity of symptoms. The DASS-21 has been
adapted to Portuguese and has been found to have satisfactory
psychometric properties (Pais-Ribeiro et al., 2004). In the
current sample, internal consistency reliability coefficient was
adequate for Depression ( ¼ 0.85), Anxiety ( ¼ 0.81), and
Stress ( ¼ 0.81) sub-scales.
Studies have shown validity data for the use of the
measures during pregnancy, stressing that the self-rated scales
used in the present study can be effective tools in identifying
worries, marital satisfaction, relationship intimacy, and emo-
tional distress, although the use of scales longitudinally across
the perinatal period influence optimal cutpoints (Ji et al.,
2012). Additionally, the literature shows that anxiety, depres-
sion, or stress impact ratings of intimacy and marital
satisfaction (Malary et al., 2015).
Statistical analysis
The statistical analyses were conducted using SPSS for Mac
OSX version 22 software (SPSS Inc., Chicago, IL).
Descriptive analysis of demographic, medical, and psycho-
logical variables was performed. Mean and standard
deviation were computed for continuous variables.
Categorical variables were described as absolute and
relative frequencies. Furthermore, t-tests (for continuous
variables) and Chi-square tests (for nominal variables) were
conducted to compare demographic, medical, and psycho-
logical variables between multiparous pregnant women and
primaparous pregnant women. In order to analyse the
association between worries during pregnancy, relationship
intimacy, marital satisfaction, and depression, anxiety, and
stress symptoms, Pearson product moment correlation
coefficients were computed. Hierarchical regression ana-
lyses were performed to investigate the influence of worries
during pregnancy and relationship variables on depression,
anxiety, and stress symptoms, after controlling for the
effects of demographic and obstetric variables that were
significantly associated with the dependent variables. All
the independent variables that were significant in bivariate
analyses were included in the multiple linear regression
equations. A 3-step procedure was followed, with the
demographic and medical variables being entered first, the
worries variable second, and relationship variables third.
Multicollinearity was tested and VIF values were well
below 10 and the tolerance statistics all well above 0.2
(Field, 2009) showing that there was no collinearity within
our data. All statistical tests were performed at a signifi-
cance level of 0.05. The mediation analysis was run using
an SPSS macro, PROCESS (Hayes, 2013) model 4 (IV –
marital satisfaction, DV – anxiety/depression, and MV –
relationship intimacy), using 1000 bootstrap samples
for bias correction and to establish 95% confidence
intervals.
 4 E. C. V. Costa et al. J Ment Health, Early Online: 1–9

Results intimacy suggested that women reporting low-relationship

intimacy had higher levels of anxiety symptoms than women
Characteristics of participants and preliminary
not reporting it.
analysis
The mean age of the 200 pregnant women was 30.2 (SD ¼ 4.4;
Predictors of depression
range 17–41). Eighty-six percent were married or cohabited
and 14% were single. Thirty-six percent had education beyond
high school, 37% had high school, and 28% had less than a
high school education. Forty-three percent of women
participated in the work force, 44.1% were on sick leave,
and 12.8% were unemployed. A total of 46.5% reported
having a yearly income of less than 6000 E, 41% between
6000 and 12,000 E, and 12.5% more than 12,000 E. For 77.5%
of the sample, this was their first pregnancy (gestational age
Age and history of miscarriage ( ¼ –0.13, p50.05;  ¼ 0.17,
p50.01; Table 3) were the only demographic and medical
variables significantly associated with depression symptoms.
Younger women had higher levels of depression symptoms
than older women. In addition, women with a history of
miscarriage had higher levels of depression symptoms than
women without such history. Worries during pregnancy were
significantly and positively related to depression symptoms
varied between 12 and 39 weeks; M ¼ 31.4, SD ¼ 5), 22.5% ( ¼ 0.17, p50.05) and relationship intimacy was signifi-
had already a child, 11% of the women had experienced cantly and negatively related to depression symptoms
miscarriages, and 16.5% of the participants experienced a
complication during pregnancy, namely diabetes (27.3%),
bleeding (18.2%), blood pressure (15.2%), among other non-
specified problems (39%). Ninety percent of the pregnancies
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were planned. The mean value for PAIR state score was 90.89
(SD ¼ 13.69), ranging from 45 to 119. The mean score for
MLASES was 4.69 (SD ¼ 0.68; range: 3–6), and the mean
( ¼ –0.32, p50.01). Furthermore, marital satisfaction was
not significantly associated, in a multivariate analysis model,
with depression symptoms.
Predictors of stress
Of the demographic variables, only work status was signifi-
score for total CWS was 1.56 (SD ¼ 0.88; range: 0–4.31). cantly related to stress symptoms ( ¼ 0.17, p50.05;
Finally, the mean depression scale score was 3.99 (SD ¼ 5.60; Table 3). In addition, worries during pregnancy were
range: 0–32), the mean anxiety scale score was 5.69
(SD ¼ 6.80; range: 0–38), and the mean stress scale score
was 10.74 (SD ¼ 8.17; range: 0–38). Significant differences
between primaparous and multiparous pregnant women were
found for age, duration of marital status, marital status,
education level, yearly income, gestational age, history of
miscarriage, marital satisfaction, worries during pregnancy,
depression, anxiety, and stress symptoms (Table 1).
Correlations between worries during pregnancy,
marital satisfaction, relationship intimacy, and
anxiety, depression, and stress symptoms
Worries during pregnancy were positively and significantly
correlated with anxiety, depression, and stress symptoms.
Marital satisfaction and relationship intimacy were negatively
and significantly correlated with anxiety, depression, and
stress symptoms (Table 2).
Predictors of emotional distress
Predictors of anxiety
According to the standardized regression coefficients, work
status and history of miscarriage were the only demographic
and medical variables significantly associated with anxiety
significantly related to stress symptoms ( ¼ 0.30,
p50.001), suggesting that women who worry more have
more stress symptoms than women who do not. No relation-
ship variables were significantly related to stress symptoms.
The first model with only the demographic and medical
variables explained approximately 11% of the variance in
anxiety symptoms (R2 ¼ 0.11). In the second and third models,
the demographic and medical variables had lower R2s of 0.05
and 0.06, suggesting a weaker role for medical and demo-
graphic variables in explaining depression (5%) and stress
symptoms (6%). Adding worries during pregnancy led to a
significant improvement (R2 change ¼ 0.09, F(1,187) ¼ 20.29,
p50.000, R2 change ¼ 0.053, F(1,194) ¼ 11.39, p50.001, R2
change ¼ 0.11, F(1,189) ¼ 24.45, p50.000, respectively):
specifically an additional 9% of the variance in anxiety, a
5.3% of the variance in depression, and an 11% of the
variance in stress symptoms were explained by worries during
pregnancy. Finally, adding relationship variables led to
significant improvement of the anxiety and depression
models (R2 change ¼ 0.04, F(2,185) ¼ 4.32, p50.015, R2
change ¼ 0.081, F(2,192) ¼ 9.56, p50.000, respectively) but
not of the stress model (R2 change ¼ 0.011, F(2,187) ¼ 1.25,
p ¼ 289). More specifically, an additional 4% of the variance
in anxiety, an 8.1% of the variance in depression, and a 1.1%
of the variance in stress symptoms were explained by
symptoms ( ¼ 0.19, p50.01;  ¼ 0.21, p50.01; Table 3).
The positive regression coefficient for both variables sug-
gested that women who were unemployed and those who had
a history of miscarriage had higher levels of anxiety
symptoms than employed ones and those not reporting
miscarriages. Worries during pregnancy and anxiety symp-
relationship variables, specifically by relationship intimacy.
The total proportion of variance explained in anxiety,
depression, and stress symptoms explained by all the inde-
pendent variables was 24, 18.5, and 18.2%, respectively
(Table 3).
Therefore, being unemployed or on sick leave, being
toms were also associated ( ¼ 0.25, p50.001). Furthermore, younger, having a history of miscarriage, having more
relationship intimacy was also associated with anxiety worries during pregnancy, and a low-relationship intimacy
symptoms ( ¼ –0.20, p50.05) but marital satisfaction was were the main predictors of emotional distress in pregnant
not. The negative regression coefficient for relationship women.
 DOI: 10.1080/09638237.2017.1417545 Emotional distress in pregnant women 5
Table 1. Demographic, medical, and psychological characteristics of pregnant women (n ¼ 200).

Cohort n ¼ 200 Primaparous n ¼ 155 Multiparous n ¼ 45

M SD M SD M SD pa
Demographic variables
Age 30.24 4.41 29.75 4.25 31.93 4.59 0.020
Duration of marital relationship 4.22 2.64 3.81 2.30 5.71 3.24 0.000
n % n % n %
Marital Status 0.001
Married 136 68.0 95 61.3 41 91.1
Cohabitating 36 18.0 33 21.3 3 6.7
Single 28 14.0 27 17.4 1 2.2
Educational level 0.029
High school attendance 55 27.6 36 23.2 19 43.2
High school diploma 73 36.7 59 38.1 14 31.8
College degree 71 35.7 60 38.7 11 25
Yearly income 0.030
Less than 6,000E 93 46.5 79 51 14 31.1
Between 6,000–12,000E 82 41.0 56 36.1 26 57.8
More than 12,000E 25 12.5 20 12.9 5 11.1
Work status 0.670
Employed 84 43.1 67 44.4 17 37.8
Unemployed 25 12.8 20 13.2 5 11.1
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Sick leave 86 44.1 64 42.4 22 48.9

Medical variables
Gestational age (weeks) 31.4 5.0 31.48 4.88 31.20 5.497 0.015
n % n % n %
Pregnancy planning 0.827
Only by the mother 1 0.5 1 0.6 0 0
By both 179 89.5 138 89 41 91.1
Not planned 20 10 16 10.3 4 8.9
Pregnancy complications 0.525
Yes 33 16.5 26 16.8 7 15.6
No 167 83.5 129 83.2 38 84.4
Health problems during pregnancy 0.534
Gestational 5 15.2 5 20 0 0
Hypertension
Diabetes 9 27.3 7 28 2 25
Bleeding 6 18.2 4 16 2 25
Other health problems 13 39.4 9 36 4 50
History of miscarriage 0.000
Yes 22 11 0 0 22 48.9
No 178 89 155 100 23 51.1
Psychological variables
Relationship intimacy 90.89 13.69 90.61 13.96 91.86 12.85 0.594
Marital satisfaction 4.69 0.68 4.69 0.64 4.70 0.79 0.000
Worries during pregnancy 1.56 0.88 1.59 0.89 1.46 0.85 0.003
Depression 3.99 5.60 3.86 5.71 4.44 5.26 0.008
Anxiety 5.69 6.80 5.21 6.62 7.33 7.24 0.018
Stress 10.74 8.17 10.6 7.81 11.20 9.39 0.000
a
Estimated by t-tests for differences in means and the Pearson 2 of independence.
M: mean; SD: standard deviation.

Table 2. Correlations between worries during pregnancy, marital satisfaction, relationship intimacy, anxiety,
depression and stress symptoms.

1 2 3 4 5 6
1 Worries during pregnancy _
2 Marital satisfaction 0.252** _
3 Relationship intimacy 0.215** 0.760** _
4 Anxiety 0.313** 0.177* 0.227** _
5 Depression 0.235** 0.244** 0.330** 0.762** _
6 Stress 0.340** 0.167* 0.191** 0.720** 0.657** _

*p50.05.
**p50.01.
 6 E. C. V. Costa et al. J Ment Health, Early Online: 1–9

Table 3. Predictors of emotional distress.

Anxiety Depression Stress

B SE  t B SE  t B SE  T
Step 1
Constant 10.92 3.79 10.03 2.72 19.99 5.40
Age 0.24 0.12 0.15 2.08* 0.21 0.09 0.16 2.35* 0.18 0.14 0.09 1.26
Education 0.79 1.01 0.06 0.78
Work status 1.39 0.50 0.19 2.77** 1.55 0.62 0.18 2.52*
Miscarriage 4.39 1.54 0.20 2.85** 2.94 1.27 0.16 2.32*
Planned pregnancy 3.62 2.08 0.13 1.74
F (4,188) ¼ 6.01 (2,195) ¼ 5.30 (3,190) ¼ 4.35
R2 0.11*** 0.052** 0.064**
Step 2
Constant 7.39 3.69 7.18 2.78 14.33 5.22
Age 0.21 0.11 0.13 1.88y 0.19 0.09 0.15 2.18* 0.16 0.14 0.08 1.18
Education 1.30 0.97 0.09 1.34
Work status 1.25 0.48 0.17 2.60* 1.39 0.58 0.16 2.38*
Miscarriage 4.26 1.47 0.19 2.90** 2.92 1.24 0.16 2.36*
Planned pregnancy 0.325 1.96 0.11 1.66
Worries during pregnancy 2.27 0.50 0.30 4.51*** 1.45 0.43 0.23 3.37** 3.01 0.61 0.33 4.95***
F change (1,187) ¼ 20.29 (1,194) ¼ 11.39 (1,189) ¼ 24.45
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R2 0.20*** 0.104*** 0.17***

DR2 0.09*** 0.053** 0.11***

Step 3
Constant 15.26 4.86 17.53 3.94 18.71 6.16
Age 0.19 0.11 0.12 1.73 0.17 0.08 0.13 1.99* 0.16 0.14 0.08 1.17
Education 1.00 0.96 0.07 1.04
Work status 1.40 0.48 0.19 2.94** 1.47 0.58 0.17 2.51*
Miscarriage 4.61 1.45 0.21 3.18** 3.12 1.19 0.17 2.62**
Planned pregnancy 2.13 2.08 0.07 1.02
Worries during pregnancy 1.94 0.52 0.25 3.76*** 1.08 0.43 0.17 2.54* 2.78 0.63 0.30 4.41***
Relationship intimacy 0.10 0.05 0.20 2.06* 0.13 0.04 0.32 3.14** 0.06 0.06 0.10 0.98
Marital satisfaction 0.11 1.00 0.01 0.11 0.28 0.85 0.03 0.33 0.18 1.25 0.02 0.15
F change (2,185) ¼ 4.32 (2,192) ¼ 9.56 (2,187) ¼ 1.25
R2 0.24*** 0.185*** 0.182***
DR2 0.04* 0.081*** 0.011

yp50.062.
*p50.05.
**p50.01.
***p50.001.

Table 4. Bootstrap analyses of the magnitude and statistical significance of indirect effect.

Dependent B mean 95% CI mean

Independent variable Mediator variable variable indirect effect SE of mean indirect effect (lower and upper)
Marital Satisfaction ! Relational Intimacy ! Anxiety 0.9314 5.4905 (0.0041, 3.5947)
Marital Satisfaction ! Relational Intimacy ! Depression 1.0000 0.7482 (0.3015, 3.0577)
Marital Satisfaction ! Relational Intimacy ! Stress 0.6890 3.2190 (0.4828, 4.7043)

Mediating effects of relational intimacy on the relationship Discussion

between marital satisfaction and psychological symptoms
The indirect effect of marital satisfaction on anxiety (95% CI
[0.0041, 3.5947], p ¼ 0.04) and depression (95% CI [0.3015,
3.0577], p ¼ 0.001) was mediated by relationship intimacy.
However, the indirect effect of marital satisfaction on stress
was not mediated by relationship intimacy (95% CI [–0.4828,
4.7043], p ¼ 0.16), (Table 4; Figure 1 and 2). We can
conclude that relationship intimacy is a mediator variable and
that it allows one to show a relation between marital
satisfaction and emotional distress.
We investigated the influence of worrying during pregnancy,
relationship intimacy, and marital satisfaction on anxiety,
depression, and stress symptoms in pregnant women, after
controlling for the effects of demographic and medical
variables, and we assessed the mediating effect of relationship
intimacy on marital satisfaction and emotional distress. Our
result is supported by previous studies showing that demo-
graphic, medical, individual, and relationship factors are
associated with pregnant women’s emotional distress
 DOI: 10.1080/09638237.2017.1417545
Relationship Intimacy (M)
a = 15.4151*** b = −0.1083*
c = −1.7918**
Marital Satisfaction (X) Anxiety (Y)
c’ = -0.1229
Figure 1. Mediation effects of relationship intimacy in the relationship
between marital satisfaction and anxiety, N ¼ 198.
Relationship Intimacy (M)
a = 15.4151*** b = −0.1402***
c = −2.0367***
Marital Satisfaction (X) Depression (Y)
c’ = 0.1245
Figure 2. Mediation effects of relationship intimacy in the relationship
between marital satisfaction and depression, N ¼ 198.
Downloaded by [193.126.83.109] at 02:30 28 December 2017
(Gourounti et al., 2013; Melville et al., 2010; Røsand et al.,
2011).
The results suggested that anxiety, depression, and stress
symptoms in pregnant women were statistically dependent on
age, working and health status, and previous obstetric
complications. In addition, we confirmed the result of
previous studies that young economically disadvantaged
women with a history of miscarriage tend to experience
more emotional problems during pregnancy (Gourounti et al.,
2013; Melville et al., 2010).
Worries during pregnancy about socio-medical, relation-
ship, reproductive-loss, health, and socio-economic problems
also influenced maternal emotional functioning, contributing
to higher distress levels. The relationship between worrying
during pregnancy and anxiety, depression, and stress symp-
toms, and the contribution of such worrying to the explanation
of emotional distress in pregnant women, confirms the
practical need to intervene at the educational level in order
to promote mental health among pregnant women.
Additionally, some of the variance in anxiety, depression,
and stress symptoms was accounted for by worrying during
pregnancy (9%, 5.3% and 11%, respectively), even when
demographic, medical, and relationship variables were
allowed as variables in the models. Furthermore, for anxiety,
depression, and stress symptoms, worrying during pregnancy
was the significant predictor with highest weight in every
final model (except for the depression model), suggesting that
worries during pregnancy were more important than demo-
graphic, medical, and relationship variables in accounting for
anxiety and stress symptoms in pregnant women. These
findings are consistent with previous research that found pre-
partum worries to be strongly associated with anxiety and
stress symptoms among the other variables studied (Szabó,
2011). Therefore, these results provide additional support for
the role of individual cognitive variables in determining
psychological health. At a practical level, these findings
suggest that worries during pregnancy are a psychological
risk factor for emotional distress.
Emotional distress in pregnant women 7
This study also confirmed and extended previous results of
a negative association between relationship variables and
emotional distress (Gourounti et al., 2014; Røsand et al.,
2011, 2012). One of the goals was to assess the impact of
relationship variables’ role after the inclusion of individual
variables. The results showed that they played an important
role in predicting anxiety (4%) and depression symptoms
(8.1%) but not stress symptoms. An important empirical
finding was the fact that low-relationship intimacy was the
variable with the strongest weight in the final model of
depression symptoms. Contrary to what one could expect
from the literature, marital satisfaction did not help signifi-
cantly to explain emotional distress. Instead, other studies
found dissatisfaction with the relationship with one’s partner
to be a significant predictor of emotional distress (Røsand
et al., 2011, 2012; Whisman et al. 2011). However, the power
of the importance of marital satisfaction may have been
undermined by the strength of relationship intimacy as a
predictor of anxiety and depression symptoms, calling
attention to the possible buffering effect of relationship
intimacy on the effects of some risk factors (Farmer &
Sundberg, 2010). At the psychological level, relationship
intimacy may be a protective factor against emotional distress
during pregnancy. Indeed, the results showed that the indirect
effect of marital satisfaction on anxiety and depression
symptoms was mediated by relationship intimacy, which
confirms the centrality of relationship intimacy in explaining
the influence of the relationship variables. This finding is
consistent with the relationship intimacy model (Manne &
Badr, 2008), which considers the marital relationship as a
resource and highlights the importance of relationships and
communication behaviors that sustain and enhance relation-
ships during stressful times, such as pregnancy. Therefore, the
results provide support for the role of relationship intimacy as
a protective factor against emotional distress during preg-
nancy. At a practical level, the findings suggest that psycho-
logical interventions with pregnant women should promote
behaviors (e.g. communication skills) that increase the level
of closeness within the couple (Malary et al., 2015).
According to the results, focussing on increased worrying
during pregnancy and promoting behaviours (e.g. communi-
cation) that increase the level of closeness within couples
should improve the psychological well-being of pregnant
women (Loke & Poon, 2011; Manne & Badr, 2008). In
addition, psycho-educational programs for pregnant women
should aim at enhancing their knowledge of pregnancy
processes and reduce worrying, e.g. through cognitive-
behavioral therapy (CBT) for depression and/or anxiety that
might reduce worrying (Hofmann et al., 2012). However,
there is limited evidence about the use of CBT in pregnant
women who worry (Chandra et al., 2010). Finally, the current
results also suggest that interventions should aim at improving
pregnant women’s relationships to reduce their emotional
distress (e.g. through communication skills training and
couples’ intimacy-enhancing interventions based on the
relationship intimacy model; Manne & Badr, 2008).
This study has several limitations that should be acknowl-
edged. The first concern is its cross-sectional nature that
makes it difficult to make causal inferences. A second
limitation is that the findings of this study are limited by the
 8 E. C. V. Costa et al.
validity of the self-reported data. Finally, the study did not
cover several predictors that could also be important in
explaining emotional distress during pregnancy, such as
mental health problems, deficient support from one’s
extended family and friends, and loss of resources, among
others. The inclusion of these variables could optimise the
prediction of emotional distress since there is a low amount of
variance explained by the hierarchical regression models.
This study highlights the importance of the worries during
pregnancy and relationship intimacy in shaping pregnant
women’s emotional distress. It is important, in future studies,
to use a longitudinal design to allow pathways between the
experience of pregnancy, pre-partum worrying, relationship
intimacy, and emotional distress to be explored from the first
to the third trimester of pregnancy. Also, the exploration of
additional mediators of the relationship between pre-partum
worrying, relationship intimacy, and emotional distress, as
well as treatment interventions to diminish and modify pre-
partum worrying and to enhance relationship intimacy among
pregnant women, are interesting future research areas. Also,
Downloaded by [193.126.83.109] at 02:30 28 December 2017
as previously mentioned, psychological distress during preg-
nancy has potential long-term effects of early-life stress on a
child’s health and perturbs the physiological milieu of
pregnancy. Future research on interventions should examine
the usefulness of mindfulness-based programs to reduce pre-
natal psychological stress (Isgut et al., 2017).
In conclusion, after controlling the effects of demographic
and medical variables, pre-partum worrying and deficient
relationship intimacy played important roles in explaining
women’s emotional distress during pregnancy. Interventions
for early recognition of symptoms should target younger,
unemployed, or on sick leave women with a history of
miscarriage, a tendency to worry during pregnancy, and non-
satisfying relationship intimacy. For this reason, pre-partum
worrying and relationship intimacy should be the target of
primary and secondary prevention. The findings also revealed
the need for antenatal services to consider including testing
for emotional distress in routine antenatal care.
Declaration of interest
No potential conflict of interest was reported by the authors.
Funding
Portuguese Foundation for Science and Technology [PEst-
OE/FIL/UI0683/2014].
ORCID
Eleonora C. V. Costa http://orcid.org/0000-0002-8586-
7775
M. Graça Pereira http://orcid.org/0000-0001-7987-2562
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