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Post-Partum Depression, Personality and Cognitive-

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Emotional Factors: A Longitudinal Study on Spanish
Pregnant Women
a b c
Cecilia Peñacoba-Puente , Dolores Marín-Morales , Francisco Javier Carmona-Monge & Lilian
d
Velasco Furlong
a
Department of Psychology, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,
Alcorcón, Madrid, Spain
b
Department of Obstetrics, Hospital Universitario de Fuenlabrada; and Department of
Nursing, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
c
Department of Nursing, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
d
Department of Psychology, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,
Alcorcón, Madrid, Spain
Accepted author version posted online: 13 Jul 2015.

To cite this article: Cecilia Peñacoba-Puente, Dolores Marín-Morales, Francisco Javier Carmona-Monge & Lilian Velasco
Furlong (2015): Post-Partum Depression, Personality and Cognitive-Emotional Factors: A Longitudinal Study on Spanish
Pregnant Women, Health Care for Women International, DOI: 10.1080/07399332.2015.1066788

To link to this article: http://dx.doi.org/10.1080/07399332.2015.1066788

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 ACCEPTED MANUSCRIPT

Running head: PREDICTIVE FACTORS OF POST-PARTUM DEPRESSION

Post-Partum Depression, Personality and Cognitive-Emotional Factors: A Longitudinal

Study on Spanish Pregnant Women

Cecilia Peñacoba-Puente

Department of Psychology, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,

Alcorcón, Madrid, Spain

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Dolores Marín-Morales

Department of Obstetrics, Hospital Universitario de Fuenlabrada; and Department of Nursing,

Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain

Francisco Javier Carmona-Monge

Department of Nursing, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain

Lilian Velasco Furlong

Department of Psychology, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,

Alcorcón, Madrid, Spain

Abstract

In this study, our purpose was to examine whether personality and cognitive factors could be

related to postpartum depression, mediated by anxiety, in Spanish women. Women were

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evaluated for personality and cognitive factors after the first trimester, for anxiety in the third

trimester and for post-partum depression four months after childbirth. A structural equation

model revealed that personality and cognitive factors were associated with anxiety and post-

partum depression as predictors. Neuroticism and extroversion proved to be the most relevant

factors. Conscientiousness was associated to pregnancy anxiety. Pregnancy anxiety appeared as

an independent predictor of post-partum depression. The model here presented includes

personality, cognitive and emotional factors as predictors of post-partum depression.

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Comprehensive care for pregnant women should contemplate assessment and intervention on all

these aspects. Special focus should be on cognitive factors and emotional regulation strategies,

so as to minimize the risk of later development of emotional disorders during puerperal phases.

Received 26 Mar 2014; accepted 24 Jun 2015.

Address correspondence to Cecilia Peñacoba Puente, Department of Psychology,

Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922

Alcorcón, Madrid, Spain. E-mail: cecilia.penacoba@urjc.es

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The birth of a new child does not always generate the positive emotional states and feelings of

wellbeing which could be expected in the mothers. Internationally, it has been widely shown

that in the puerperal phase there is a high risk of development of affective disorders such as

postpartum blues, puerperal psychosis, post-traumatic stress disorder and post-partum depression

(Brockington, Macdonald, & Wainscott, 2006).

Specifically, post-partum depression has been recognized as a potential consequence of

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pregnancy, labor, and childbirth and has garnered increasing attention in recent years (Vliegen,

Casalin, & Lyuten, 2014). According to the World Health Organization (WHO), depression is

the leading cause of disability worldwide (WHO, 2012).

Our main objective in this study has been to examine the role of personality and cognitive

factors in the prediction of postpartum depression.

Post-partum depression (PPD) is defined in the Diagnostic and Statistical Manual of

Mental Disorders V (DSM-V) as a major depressive disorder that is produced specifically after

childbirth, with onset during the first month after birth (American Psychiatric Association,

2013). However, research about the onset and evolution of this disorder has widened the concept

of it, and it’s now considered as a depressive state that can span from pregnancy to a year after

childbirth (Gavin et al., 2005).

Incidence of post-partum depression is between 10%-25% (Dennis & Dowswell, 2013),

although there seems to be a great variability influenced by socio-cultural elements (Halbreich &

Karkun, 2006). This disorder often can remain in a large percentage of women during the first

year especially in the most severe cases (Beeghly et al., 2002; Horwitz, Briggs-Gowan, Storfer-

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Isser, & Carter, 2007). As Patel et al. (2012) suggested, postpartum depression is a disorder that

is often unrecognized and undertreated. Management of postpartum depression is a vital part of

adequate medical care. To prevent adverse outcomes associated with depression and its impact

on the child, it is important that all health care professionals are aware of specific signs and

symptoms, appropriate screening methods, and proper treatment. There are a number of factors

that influence the onset and maintenance of PPD, including biological, psychological and socio-

cultural factors (Gale & Harlow, 2003).

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From the different psychological predictor factors analyzed in association to PPD, in this

study we have focused on previous emotional states (specifically anxiety), personality and

certain cognitive variables such as worries, lack of control and expectations. It should be pointed

out that even though previous literature on PPD and emotional states is abundant there is a

certain lack of research into the role that personality and cognitive variables play in PPD.

Previous Emotional States

Depressive symptoms during pregnancy have been associated to the later development of

PPD (Milgrom et al., 2008; Saisto, Salmela-Aro, Nurmi, & Halmesmaki, 2001). Some studies

have considered ante-natal depression as a factor that can independently influence other variables

and can predict PPD (Kim, Hur, Kim, Oh, & Shin, 2008; Verkerk, Pop, Van Son, & Van Heck,

2003). However, results have been shown to differ depending on how depression and PPD are

assessed as well as on the type of design used in the study (cross-sectional vs. longitudinal), this

could be due to methodological and conceptual overlap (McCoy et al., 2008; Milgrom et al.,

2008).

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Different studies have associated the presence of anxiety during pregnancy to PPD

(Coelho, Murray, Royal-Lawson, & Cooper, 2011; Horwitz et al., 2007; Mohammad, Gamble, &

Creedy, 2011; Mori et al., 2011), which has been found to be a strong independent predictor

(Austin, Tully, & Parker, 2007).

Anxiety and depression are different disorders, however some of the characteristics are

shared. These overlapping characteristics may explain some of the different results found by

some authors (Brockington et al., 2006; Goodman & Tyer-Viola, 2010).

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Personality

The five-factor model (Costa & McCrae, 1995) has been widely accepted as a frame of

reference for the examination of personality. This model establishes the existence of the “Big

Five” independent traits, the combination of which describes one’s personality. The Big Five are:

neuroticism (which addresses emotional adjustment, identifying those people with a tendency for

psychological distress and non-adaptive coping strategies), extraversion (which refers to the

quantity and intensity of interactions among people, activity level, need for stimulation, and

capacity for enjoyment), openness to experience (receptiveness to new situations), agreeableness

(a tendency to be empathic, compassionate and cooperative rather than suspicious or antagonistic

toward others) and conscientiousness (which refers to the degree of organization, persistency,

control, and motivation in goal-directed behaviour) (Boyle, Matthews, & Saklofske, 2008).

From the perspective of the Big Five model, there is evidence that neuroticism is

positively associated to generalized anxiety disorder (Bienvenu et al., 2001), whilst extroversion

is associated negatively to anxiety disorders (Gomez & Francis, 2003). Openness and

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conscientiousness negatively associate to obsessive-compulsive disorder and agreeableness also

associates negatively with post-traumatic stress disorder (Chung, Berger, Jones, & Rudd, 2006).

As for depressive symptoms, it has been found that there is an influence of neuroticism

on the onset (Goodwin & Gotlib, 2004; Peñate, Perestelo, Bethencourt, & Ramírez, 2009), and

recurrence of depressive episodes (Steunenberg, Braam, Beekman, Deeg, & Kerkhof, 2009).

Different authors have shown that, when a person suffers from a depressive disorder, scores on

neuroticism and extroversion are influenced by this depressive state, and they are subject to
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change when the depressive episode improves, whilst the other three personality factors remain

stable (Griens, Jonker, Spinhoven, & Blom, 2002).

Among the studies specific to PPD, neuroticism is the trait that associates positively most

often, along with introversion (Jones et al., 2010; Saisto et al., 2001; Verkerk, Denollet, Van

Heck, Van Son, & Pop, 2005).

Cognitive Factors

There has been a significant amount of evidence about the negative effect of worries

during pregnancy and dysfunctional beliefs on the psychological symptoms shown after

childbirth (Jones et al., 2010). Some studies have shown that there is a positive association

between worries and anxiety during pregnancy (Peñacoba, Carmona, Carretero, & Marin, 2011).

Different studies have shown that a larger number of worries during pregnancy increase the risk

of PPD (Austin et al., 2007; Mohammad et al., 2011; Redshaw, Martin, Rowe, & Hockley,

2009), especially if these worries are about fetal health and care-taking of the newborn (Leung,

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2001). Obsessive thoughts are also associated to post-partum psychological disorders

(Abramowitz et al., 2010).

Processes such as self-efficacy and locus of control are involved in wellbeing and

psychological health. Women with negative self-efficacy expectations, and low parenting self-

efficacy show a higher probability of having depressive symptoms (Davey, Tough, Adair, &

Benzies, 2011; Gremigni, Mariani, Marracino, Tranquilli, & Turi, 2011; Mohammad et al.,

2011), which are increased even further when the woman has negative expectations about
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motherhood (Harwood, McLean, & Durkin, 2007). The influence of expectations has been

shown in studies aimed at assessing the effects of treatment of PPD, showing that when realistic

expectations about child-care and child behavior are strengthened there is an improvement of

depressive symptoms (Khazan, 2005).

Different studies have shown that when there is an increase in control perception

of situations this has a protective effect on new parents mental health, including PPD (Keeton,

Perry-Jenkins, & Sayer, 2008). It has been found that new mothers diagnosed with depression

have a sense of loss of control over their lives (Milgrom et al., 2008).

In spite of the evidence that both personality and cognitive factors influence the

development of PPD, we are not aware of any literature integrating both these factors in an

explanatory model. In this context, the diathesis-stress models offer an explanatory framework

for depression, where certain psychological vulnerability factors are prioritized, amongst which

we can find cognitive factors (Hammen, 2005). From this perspective, our research question

focuses on the confirmation of a single integrating model that includes the role that certain

cognitive (pregnancy worries, locus of control and expectations) and personality variables as

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possible psychological vulnerability factors that influence PPD, both indirectly and through

emotional states during pregnancy (anxiety). Ultimately, the purpose of the current study has

been to join these factors (personality, cognitive factors and anxiety) in a single integrating

model to predict post-partum depression, using a longitudinal design, on Spanish pregnant

women.

Method
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Design and Sample

A longitudinal prospective design was used. The convenience sample was assessed on

three separate occasions; after the first trimester (personality and cognitive factors), third

trimester (anxiety) and post-partum (PPD). Based on our review of the literature, we chose the

end of first trimester to assess the predicting variables of our model (possible vulnerability

factors), and the third trimester as the appropriate moment to assess the emotional state during

pregnancy as an additional relevant predictive factor. The sample at the initial data collection

point consisted of 285 pregnant women receiving obstetric care at a public university hospital

situated in South Madrid. Recruitment criteria were: Women > 18 years of age, who were

mentally healthy (not previously diagnosed of any mental disorder by a clinician), with a

maximum gestational age of 14 weeks, and who had not been diagnosed with any maternal or

fetal diseases. The women’s mean age in the sample was 31.5 years (SD = 4.9; ranging from 23

to 43 years old) and 50.2% were first-time mothers. Of these women, 27.5% had completed

primary education, 45.4% had completed secondary education, and 27.1% had attended college.

About a quarter of the women (27.7%) had experienced at least one previous miscarriage or a

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voluntary interruption of pregnancy before the current one; 82.8% of the pregnancies had been

planned. In all, 65.4% of the women were working outside the home. Of the 285 women

recruited in the study, 122 continued their participation in the study in the third trimester, and

116 four months after childbirth. The mean gestational age was 14.4 weeks (SD = 2.1) at the

initial data collection point and 34.3 weeks (SD = 2.3) at the third trimester.

The ethics committee of the hospital approved the study, and all participants completed

an informed consent form.

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Procedure

A midwife who was part of the research team established the first contact with the

participants personally at the antenatal clinic at the first-trimester ultrasound, around 12-13th

week of pregnancy. The first trimester sample was assessed between October 2009 and April

2010. During those months, the midwife assessed women who had obstetric care appointments

(using the electronic clinical record) that met the inclusion criteria. The women were then

informed about and invited to participate in the study. We approached 320 eligible women. Of

these, a total of 292 (91.25%) agreed to participate in the study, and signed the informed consent

form.

Once the women were enrolled, they were given a battery of questionnaires that included

questions about demographic and pregnancy variables and all the validated measures detailed in

the instruments section. The relevant clinical variables were subsequently obtained from the

hospital’s medical records. The completed questionnaires were returned directly to the researcher

or were sent by mail within one week. Two of the participants suffered miscarriages during this

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period and were therefore excluded from the analysis. 285 expectant mothers, therefore, made up

the final sample at the initial data collection point (at the end of first trimester).

In the third trimester (around week 30), the Symptom Checklist-90-R (SCL-90-R) was

mailed to the women with a prepaid envelope in which to return the completed questionnaire to

the research team.

Before the second questionnaire was sent, each participant’s medical records were

reviewed to confirm that none of the exclusion criteria had been met during this period. Five
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women had a miscarriage in the first half of their pregnancies, after completing the first

questionnaire. The remaining enrolled women received a telephone call in which they were

asked to return the second questionnaire upon completion. Thus, 280 questionnaires were mailed

in the third trimester and 122 of them were returned (43.6%).

Finally, four months after childbirth the same procedure was used, the women were

contacted over the phone and were sent the Edinburg Postnatal Depression Scale (EPDS), of

these 115 questionnaires were returned (94.2%). The loss of participants is similar to that

obtained in comparable longitudinal studies, and there were no significant differences in

sociodemographic or pregnancy variables between the first, third trimester and postpartum

samples. Also, no statistically significant differences were observed for any of the variables

assessed in the first trimester of pregnancy (personality, pregnancy worries, locus of control and

childbirth expectations dimensions) between the women that remained in the study until

postpartum and those that dropped out after the first trimester.

Variables and Instruments

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Post-partum depression. The Spanish version of the Edinburg Postnatal Depression

Scale (EPDS) was used (Garcia-Esteve, Ascaso, Ojuel, & Navarro, 2003). This scale consists of

10 multiple choice items, with 4 options each. Cut-off score for major depression had been

established at 10/11, with a sensitivity of 100%, and specificity of 92%, and a PPV of 28.8%.

Psychometric studies of the test have shown an alpha value of .87, sensitivity of 85%, specificity

of 77%, positive predictive value of 83%. Reliability of all assessment instruments used in the

study can be found in Table 1.

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Anxiety. The Spanish version of the anxiety sub-scale of the Symptom Checklist-90-R

was used (González de Rivera et al., 1989). The SCL-90-R is a brief, multidimensional self-

report inventory designed to assess a broad range of psychological clinical symptoms. The

instrument consists of 90 items, rated on a 5-point Likert-type scale, measuring nine dimensions:

somatization (12 items), obsessive-compulsiveness (10 items), interpersonal sensitivity (9 items),

depression (13 items), anxiety (10 items), hostility (6 items), phobic anxiety (7 items), paranoid

ideation (6 items), and psychoticism (10 items). The instrument also contains a dimension for

miscellaneous symptoms (7 items). The mean score for each dimension can range from a

minimum of 0 (not at all) to a maximum of 4 (extremely). Results of previous studies show high

internal consistency for the instrument’s nine subscales (Robles, Andreu, & Peña, 2002).

Personality. The Spanish version of the el Neo Five Factor Inventory (NEO-FFI) was

used (Seisdedos, 1999). The NEO-FFI is a shortened version of the NEO-PI-R (the NEO

Personality Inventory) (Costa & McCrae, 1992). It contains 60 statements rated on a Likert-type

scale ranging from 0 (strongly disagree) to 4 (strongly agree). It measures the five main factors

of personality: neuroticism, extraversion, openness to experience, agreeableness, and

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conscientiousness. Each dimension (having 12 corresponding statements) can receive a score

from a theoretical minimum of 0 to a maximum of 48. Results of the exploratory and

confirmatory factor analyses have confirmed its factor structure (Ludtke, Trautwein, Nagy, &

Koller, 2004).

Locus of control (LOC). We used Rotter´s Locus of Control Scale, which provides a

measure of perceived LOC in different situations of everyday life; this scale is composed by 29

items, 23 assess general expectations about control over rewards and 6 distracting items aimed at
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making the purpose of the scale less clear (Rotter, 1966). Each item is made up of two sentences,

one about external control expectations and another about internal control expectations, in each

item the participant much choose one of the sentences. From the scale a total score can be

derived from adding the items answered in the direction of external control, therefore a higher

score indicates a higher external control locus. In this study we used the Spanish version of the

scale (Pérez, 1984). This test is reliable and validity studies support the construct (Smith,

Trompenaars, & Dugan, 1995).

Childbirth expectations. Childbirth expectations were assessed using Kao’s (2004)

modification of the Childbirth Expectations Questionnaire (Kao, Gau, Wu, Kuo, & Lee, 2004).

It’s composed of 37 items, that reflect different expectations about the birth of the child, each has

5 different possible responses on a Likert-type scale, ranging from 1 (completely disagree) to 5

(completely agree). Factor analysis has shown a five factor structure: care-giving environment,

partner support, control and participation, health care support and labor pain expectations. All

dimensions are expressed positively. The Spanish version was created using the

recommendations for adaptation of tests (Hambleton & Patsula, 1999), in which four translators

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with high levels of understanding of both language and culture of Spanish and English generate

versions of the questionnaire. In Kao’s study global reliability was acceptable, but there was no

report on reliability for the sub-scales (Kao et al., 2004).

Pregnancy worries. The Spanish version of the Cambridge Worry Scale (CWS) was

used (Carmona, Penacoba, Marin, & Carretero, 2012). The CWS is a self-reported questionnaire

that assesses typical concerns of pregnant women and consists of 16 items each having five

Likert-type alternatives, ranging from 0 (not a worry) to 5 (major worry). The measure
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demonstrated good reliability and validity. Principal component analysis revealed a four-factor

structure of women’s worries during pregnancy: (a) interpersonal relations, (b) socio-economic

aspects related to the pregnancy and the baby’s birth, (c) socio-medical problems, and (d) aspects

related with the mother’s, fetus’s and significant people’s health. For the current study we used

the global pregnancy worries measure.

Socio-demographic and pregnancy data. These were collected with a questionnaire

designed by the research team. The socio-demographic variables collected were age, educational

level, and employment status at the time of the study. The pregnancy variables collected were

previous childbirth, previous miscarriage, and whether the pregnancy was planned. The

remaining data, essential for determining the inclusion criteria, were taken from the clinical

records.

Statistical Analyses

To assess differences in anxiety and post-partum depression in association to the socio-

demographic and clinical variables, descriptive analysis and Student’s t test for related samples

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were used. Pearson’s correlation was used to analyze the relationship between continuous

variables. All results are presented as means (SD), and differences were considered significant at

a p level < .05. The statistical package SPSS version 17.0 was used for these analyses. For the

creation and adjustment of the model the AMOS version 7.0 program was used. Before the

analysis assumptions to ensure the realization of a Structural Equation Modelling (SEM) were

checked: sample size, multivariate normality, linearity and correlation between variables. There

are several criteria to choose the sample size when a researcher wants to apply a SEM.
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According to Hair, Anderson, Tathan, & Black (1992) the appropriate size for any SEM

procedure would be 200 cases. However, if we want to relate the size with the number of

variables, according to Jaccard & Wan (1996) we should take ten cases per observable variable.

The following criteria were used in order to fit the model:

a) χ2 statistic (Ullman, 1996).

b) The CMIN/DF is an index of how much the fit of data to model has been reduced by

dropping on one or more paths. The criteria of fit are among less than 2 (Ullman, 1996).

c) Comparative fit Index (CFI); a good index should be more than .90, and, ideally, greater

than .95 (Hu & Bentler, 1999).

d) The root mean squared error of approximation (RMSEA; Steiger & Lind, 1980) should

be less than .10, and, ideally, less than .05; it increases with the size of the sample.

e) Tucker-Lewis Index as measures of the discrepancy between the chi-squared value of the

hypothesized model of the null model. The values should take place between 0 and 1 with

a cut-off of .90 or greater indicating a good model fit (Tucker & Lewis, 1973).

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Results

Preliminary Analyses

Table 1 presents the mean, standard deviations and Pearson correlations for all study

variables.

Relationship Between Post Partum Depression and Anxiety With Socio-Demographic And

Pregnancy Data
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No statistically significant differences or correlations were found either between anxiety

or PPD and any of the socio-demographic (age, educational level, and employment status) or

clinical variables (previous childbirth, previous miscarriage, and planned pregnancy).

Variables Included in the Model

The model included all variables that had been taken into consideration: personality

factors (neuroticism, extraversion, agreeableness, conscientiousness and openness) and cognitive

factors (pregnancy worries, external locus of control and expectancies) at the end of first

trimester, anxiety at third trimester and postpartum depression. As for expectations, the

following were included in the model: caregiving environment, partner support, control and

participation and health care support, excluding therefore expectations about labor pain. This

decision was made due to the behavior of this dimension (see Table 1), because on the one hand

it does not correlate with the outcome variables (anxiety and post-partum depression), and on the

other it’s independent from the other variables on the scale, it’s very close to the concept of

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pregnancy worries and neuroticism, indicating therefore that it refers to a concept closer to worry

than to some sort of expectation.

Non-normality

In our sample, multivariate normality was tested using the Mardia test for multivariate

kurtosis. Skewness and kurtosis indexes were calculated for each variable (Table 2) and the

Mardia test suggested the presence of non-normality at a multivariate level (critical ratio =
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12.889; p < .01). Given this, the decision was made to pursue parameter estimation under two

scenarios, traditional maximum likelihood analysis and bootstrapping, which is used when the

standard assumptions do not apply. To assess the overall fit of the tested models, we used the

Bollen–Stine bootstrap p-value in addition to the usual maximum likelihood-based p value (chi

square), following Bollen and Stine’s recommendations (Bollen & Stine, 1993). In general,

conclusions were the same in the two estimation methods. Significance tests and confidence

interval reported are from the bootstrap analyses.

Model for the Predictive Role of Cognitive Factors and Personality for Anxiety and

Postpartum Depression

For testing the proposed model, a SEM analysis was carried out. In this model, we

proposed that the personality factors (neuroticism, extraversion, agreeableness,

conscientiousness and openness) and the cognitive factors (represented by pregnancy worries,

external locus of control and expectation) could influence postpartum depression mediated by

anxiety.

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The Bollen-Stine p value for this model was .005 and χ2(63) = 154.339 (p < .01), and the

relative chi-square (CMIN/DF) was 3.150 showing a poor fit. The overall fit of the model was

TLI = .82 and CFI = .86, indicating a fairly good fit to the data. Modification indexes suggested a

few parameters that could increase model fit if added to the estimation. In this regard, we noted

three covariances between errors that would increase model fit without altering the overall

structure of the model and had a theoretical rationale: between the residuals of the variables

personality and cognitive factors (modification index = 21.838), partner support and control and
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participation (modification index = 13.251). Given this, we added these covariances to the

model. After specifying these covariances, modification indexes again suggested one parameter

(between extraversion and openness; modification index = 16.35) to increase the model fit. This

new modification was added for being coherent with our theoretical framework. All of this gave

rise to the final model presented in Figure 1, with a Bollen-Stine p value of 0.025 while the rest

of the indices of global fit were: c2 = 113.20; c2/df = 1.30 (p < .01); CFI = .95; TLI = .94 and

RMSEA = .05 all of which points to an appropriate degree of fit for the model. All of the

coefficient paths were statistically significant (p < .05).

Discussion

The data adjusts well to the model, where the combined action of personality traits and

cognitive factors (expectations, locus of control and pregnancy worries) predicted negative

emotional states during pregnancy and the influence of these negative emotions on PPD.

Previous literature has highlighted the importance of these variables, to different degrees,

although it has not incorporated all of them in a single integrating model using a longitudinal

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design. Neuroticism and extraversion are the personality traits that play a crucial role in the

explanation of the model, especially neuroticism. Both traits maintain significant correlations

with both third trimester anxiety and PPD (positive correlations for neuroticism, negative for

extroversion). None of the other personality traits we assessed correlated with PPD. As

previously stated, there is scarce literature analyzing the influence of personality traits on PPD.

In spite of this, our results are coherent with studies on pregnant women that associate

neuroticism with PPD (Jones et al., 2010), and also with, the even fewer studies, that associate
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introversion with increased risk for PPD (Saisto et al., 2001; Verkerk et al., 2005).

The importance of neuroticism in the model could be due to the fact that this is a trait that

is closely connected to a tendency to suffer psychological stress and the use of unadaptative

coping strategies; this could be influencing the mothers by leading them to handle maternity in a

more dysfunctional way, increasing the risk of developing an emotional disorder (Bienvenu et

al., 2001). Neuroticism maintains positive correlations with external locus of control and with

worries, as well as with certain negative expectations (Muris, Roelofs, Rassin, Franken, &

Mayer, 2005). Some studies show the mediating effect between worries during pregnancy and

neuroticism and certain mental health results (Peñacoba et al., 2011).

In spite of the importance of neuroticism and extraversion, it’s important not to ignore the

role other personality traits play, such as conscientiousness, agreeableness and openness. Our

data supports the idea that these traits, even though they do not maintain positive correlations

with PPD do correlate indirectly through the previous emotional states (for example the

relationship between conscientiousness and anxiety) and cognitive factors. Openness,

agreeableness and conscientiousness all maintain negative associations with external locus of

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control, and positive associations with some of the expectations (agreeableness and

conscientiousness with partner support for all three, and health care support, control and

participation, and care giving environment). Even though this association has not been

previously examined in pregnancy, there are many studies about personality that associate

certain traits with cognitive variables such as locus of control or self-efficacy (Cantor, 1990;

Ebstrup, Eplov, Pisinger, & Jorgensen, 2011), therefore it’s interesting to consider the

importance of these variables.

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In addition, as previously presented, conscientiousness associates negatively with anxiety

in pregnant women during the first trimester. Different studies in general population have

reported a negative association between conscientiousness and certain anxiety disorders such as

obsessive-compulsive disorder and post-traumatic stress disorder (Chung et al., 2006).

It is important to point out that other authors have highlighted the need to study not only

disordered variables (i.e. neuroticism) but also the health promoting variables (i.e. extroversion,

openness, agreeableness and conscientiousness) (Seligman, Steen, Park, & Peterson, 2005).

Increasing health resources not only minimizes negative emotional states (i.e. PPD) but also

increases quality of life and wellbeing in people.

In addition, the model confirms the important role that emotional states play during

pregnancy and after childbirth. This is in accordance with previous studies which associate

anxiety during pregnancy with presence of PPD (Mohammad et al., 2011; Mori et al., 2011). Our

data supports the role that anxiety during pregnancy plays as a strong independent predictor of

PPD, which supports the idea presented by Austin et al. (2007). The significant, but not

excessively strong, associations between anxiety and PPD indicate that, even though anxiety is a

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precipitating factor, they are in fact independent phenomena, especially in the peri-natal period,

as previous authors have reported (Brockington et al., 2006; Goodman & Tyer-Viola, 2010). In

fact, whilst PPD is associated to neuroticism and extroversion, anxiety is also associated to

conscientiousness. It also must be considered that the cognitive factors that influence each

emotional state differ; worries and external locus of control influence both anxiety and PPD, but

expectations seem only to have an effect on anxiety. Thus, our data allows us to think about a

relative independence between cognitive factors, as much in their role as predictors of anxiety
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and PPD as in the way they associate amongst each other. We found no correlations between

pregnancy worries and any of the expectations we took into consideration (except for labor pain

expectations) and external locus of control. This shows the importance of taking into

consideration each cognitive factor independently, as each one contributes in itself to the model.

Our data is coherent with previous studies showing a positive association between worries and

pregnancy anxiety (Peñacoba et al., 2011) and PPD (Austin et al., 2007; Mohammad et al., 2011;

Redshaw et al., 2009). As for locus of control, different studies have reported the protective role

that perception of control has on the new mother’s mental health (Keeton et al., 2008). However,

when considering expectations, although there are some studies conducted during pregnancy that

associate them to depressive symptoms and PPD (Davey et al., 2011; Gremigni et al., 2011;

Mohammad et al., 2011), there are no specific studies that examine the association to pregnancy

anxiety. The fact that in our study expectations are the differentiating cognitive factor from

pregnancy anxiety indicates that there is a need to further the research in this area so as to be able

to clear the specific role that different cognitions play in emotional states generated during

pregnancy and after childbirth.

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A number of limitations in this study should be borne in mind for future research

agendas. The sample was taken from a specific geographic and cultural area, limiting the

generalizability of our findings. However, using a cut-off score of 11 for the Edinburg Postnatal

Depression Scale (EPDS) to diagnose major depression we found that 12.2% of participants in

our sample presented PPD (Garcia-Esteve et al., 2003), a percentage similar to that found in

previous studies, which range from 10%-25% (Dennis & Dowswell, 2013). Another limitation is

the use of self-report measures for all the variables studied; in future studies other types of
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measures should be used, such as observational or psycho-physiological, to be able to assess

personality and emotional states. A third limitation is the presence of covariances between

measurement errors. These correlation errors indicate that the latent variables in the model did

not fully account for the relationships among some of the measured variables. The correlation

between measurement errors of extraversion and openness indicates shared variance between

these two variables not fully accounted for by their loadings on a single personality factor,

perhaps because the two variables are measuring a similar property of the pregnant women. In

the same way, the correlation between measurement errors of partner support and

control/participation expectancies could explain a certain similarity between variables, in as

much that they both implicitly carry the participation of the pregnant woman and her partner

both during pregnancy and labor. Finally, we had a high rate of drop-outs, similar to that of

other studies (Grant, McMahon & Austin 2008; Kitamura et al., 2006) in which the observation

period spanned from pregnancy to postpartum. Different reasons about the procedure could be

contributing to the high drop out rate. At the initial data collection point, the women were

consulted personally during the first antenatal clinic visit and most of them completed and

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handed in the questionnaires in person at the antenatal clinic, and it was only a minority (less

than 20%) that returned the questionnaires through the mail after a period of a week. Also,

during that first visit a new relationship is established between the woman and the obstetric team,

which in the majority of cases is characterized by positive emotions about the pregnancy (let’s

not forget that all of the pregnancies were risk free, and mostly planned). This positive emotion,

along with the desire to please the health care worker that will be taking care of their health and

their baby’s health during the pregnancy, could be contributing to the high participation rate
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found in the first trimester (91.25%).

Nevertheless, the conditions at the third trimester are clearly different. The contact to

request them to complete the questionnaires isn’t made personally during their regular pregnancy

checkups. In the third trimester collection there is no direct contact with the midwife, as it is

done over the mail, having previously received a warning phone call. This collection procedure

is much less efficient than face to face. What’s more, at this point the women are much more

worried about childbirth, and they perceive this phase of pregnancy finished as well as their

relationship with the team at the antenatal clinic, so we could hypothesize that their interest in

participating has decreased.

In spite of these limitations, the current study presents an integrative model where

personality, cognitive and emotional aspects are presented as explanatory factors for PPD. The

fact that it’s a longitudinal study increases the validity of the results here presented. Clinical

repercussion seems obvious. On the one hand, given the stability of personality traits, treatment

of the cognitive factors presents itself as an alternative to modify negative emotional states

during pregnancy and after childbirth. On the other hand, intervention on the ‘strengths’ and not

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only on the ‘weaknesses’ should be contemplated as essential. It should, therefore, be an aim to

act preventively on PPD during pregnancy, considering that this study can be seen as a follow-up

of women during pregnancy.

The inclusion of cognitive-behavioral techniques (CBT) in the health care of pregnant

women, with specific attention to emotional regulation, would no doubt improve emotional

symptoms and increase quality of life and wellbeing in pregnant women. In particular, although

there are few studies and these refer to at risk pregnant women, these effects have been tested on
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locus of control (Yu, Wei, & Gong, 2010). Also, interpersonal psychotherapy (IPT) which

focuses on developing skills to better relate to other people, has been proven to be useful in

treatment of mental illness in women´s health (Johnson 2007), could also been another possible

alternative to take into account.

Also, work on expectations is another area to be considered. Different studies (Ayers &

Pickering, 2005; Maggioni, Margola, & Filippi, 2006) have suggested an influence of

expectations on anxiety states during pregnancy and on postpartum depression. Nevertheless, to

our knowledge, there are no studies that analyse the effects of certain intervention techniques, as

the ones suggested, on the modification of expectations or on their possible effects on associated

emotional disorders. Therefore, it would be of great interest to carry out longitudinal studies that

would allow to validate specific intervention techniques to improve quality of life of pregnant

women, both during the pregnancy as well as in the post-partum period.

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Funding

This work was funded by the Health Research Fund (Fondo de Investigaciones Sanitarias, FIS),

grant number PI07/0571 and PI10/02198 from the Instituto de Salud Carlos III (Spain).
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Table 1 Means, Standard Deviations (SD), and Pearson Correlation Coefficients for All Variables

Mean 1 2 3 4 5 6 7 8 9 10 11 12 13 14
(SD)
1. PP Depression 6.15 (.87) .53** .49** - -.08 -.10 -.31 .25* .26** -.03 -.09 -.07 -.06 -.13
(4.91) .31**
2. Anxiety 0.62 (.77) - -.08 -.13 -.18* .24* .40** - -.09 -.25* -.20* -.08
(0.55) .55** .28** .22*
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3. Neuroticism 18.05 (.81) - .05 - - - -.12 -.06 - -

(7.26) .35** .32** .37** .25** .29** .14* .17** .20**
4. Extraversion 31.52 (.79) .24** .18** .38** .12 -.06 .06 .14* .13* .10 .02
(6.06)
5. Openness 26.01 (.70) .07 .13* -.14* .08 -.06 .10 .16* .01 .00
(6.03)
6. Agreeableness 30.79 (.71) -.13* -.11 .14* .28** .22** .22** .04
(5.73) .22**
7. 31.81 (.71) - -.05 .16* .16* .16* .17** .02
Conscientiousness (5.74) .25**
8. External Locus of 13.16 (.71) .11 -.09 -.09 -.01 -.09 -.09
Control (3.23)
9. Pregnancy 1.91 (.86) -.06 -.02 .06 -.04 -
worries (0.86) .39**
10. Health care 15.96 (.79) .54** .34** .81** .02
support (2.48)
11. Control and 33.04 (.62) .43** .64** .08
participation (4.00)
12. Partner support 26.60 (.70) .41** .06
(2.78)
13. Caregiving 52.21 (.89) .00
Environment (6.64)
14. Labor pain 14.77 (.88)
(4.47)

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The Cronbach’s a coefficient for each scale is presented along the diagonal.

* p < .05; ** p < .01

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Table 2 Assessment of Normality

Variable Min Max Skew C.R. Kurtosis C.R.

Anxiety .000 2.500 2.036 14.035 7.937 27.352

Postpartum Depression .000 22.000 1.674 11.536 6.962 23.991

External Locus of Control 4.000 21.000 –.091 –.625 .176 .605

Pregnancy worries .000 4.563 .406 2.795 –.256 –.881

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Health care support 7.000 20.000 –.113 –.780 .427 1.471

Control and participation 22.000 45.000 .086 .595 .729 2.514

Partner support 18.000 30.000 –.574 –3.953 –.043 –.148

Caregiving Environment 29.000 65.000 –.140 –.968 .582 2.006

Conscientiousness 16.000 47.000 –.112 –.772 –.128 –.443

Agreeableness 12.000 47.000 –.357 –2.460 .303 1.043

Openness 9.000 43.000 –.256 –1.766 .215 .739

Extraversion 9.000 46.000 –.157 –1.081 .204 .704

Neuroticism 1.000 38.000 .185 1.278 –.155 –.533

Multivariate 30.156 12.889

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Figure 1. Final model showing the predictive role of personality, cognitive factors and

expectancies in relation to postpartum depression mediated by anxiety. Standarized path

coefficients are shown. Dotted arrows show the first suggested relationships to increase the

model fit and thick arrow show the last parameter suggested. Note: Standarised path coefficients

are shown.

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