
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-181
10.4103/jehp.jehp_352_23
Original Article
Investigating the depression, anxiety, and stress-related factors in near-miss mothers
Amiri Marjan
Kohan Shahnaz 1
Heidari Zeinab 1
Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
1 Isfahan Fertility and Infertility Center, Isfahan University of Medical Sciences, Isfahan, Iran
Address for correspondence: Dr. Zeinab Heidari, Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan - 81745-33871, Iran. E-mail: zeinab_heidari@nm.mui.ac.ir
2024
05 7 2024
13 18112 3 2023
26 6 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Life-threatening complications during pregnancy and childbirth could have an impact on the physical and mental health of mothers. The present research aimed to investigate the factors related to depression, anxiety, and stress among mothers who have survived maternal near-miss situations.

MATERIALS AND METHODS:

This is a descriptive-analytical study, and the data have been collected cross-sectionally. Near-miss mothers who had given birth within the past year were selected through the census method (having at least one criterion of the clinical, laboratory, and management standard of the World Health Organization). The Depression, Anxiety, and Stress Scale (DASS-21) and a demographic questionnaire on personal, family, fertility, and care information were filled out by these mothers.

RESULTS:

One hundred fifty-four near-miss mothers were investigated. The findings indicated that lack of social support, domestic violence, and marital dissatisfaction leads to a significant increase in the mean score of depression among near-miss mothers. In addition, according to the findings, an unemployed spouse, low level of education, lack of social support, recent unintended pregnancy, high blood pressure, and bleeding during pregnancy result in a significant increase in the mean score of stress among near-miss mothers. The findings also showed that domestic violence, a history of infertility, heart disease, and bleeding complications significantly increase anxiety in near-miss mothers.

CONCLUSION:

Considering the high levels of depression, anxiety, and stress in near-miss mothers, it is of utmost importance to pursue and check up on their mental health, as they are one of the most vulnerable groups in society. It is crucial to provide them support long after discharge to reintegrate these mothers into normal living as per the present study’s findings.

Anxiety
depression
mother
near-miss
stress
==== Body
pmcIntroduction

Mothers are at the core of the social, economic, and cultural growth of a society, and keeping them healthy both physically and mentally increases the well-being of their children, families, and society as a whole.[1] Pregnancy may negatively influence the woman and her family due to various factors, which is classified as a high-risk pregnancy.[2] The rate of maternal mortality due to pregnancy complications and childbirth is among the most critical indicators of a country’s economic, cultural, and healthcare development.[3] Annually, for every woman who passes away, at least another 20 near-miss women suffer from debilitating injuries, infections, and disabilities from pregnancy and childbirth for years.[4] The World Health Organization defines near-miss mothers as women who nearly died and suffered from severe complications during pregnancy, childbirth, and within 42 days of pregnancy termination.[5] The study by Naderi et al. indicated a maternal near-miss ratio of 25.2 per 1000 live birth in Iran.[1] This organization has recommended 25 criteria for the diagnosis of maternal morbidity or cases of near-death, which are identified based on organ dysfunction (cardiovascular, respiratory, renal, coagulation, hepatic, neurological, and uterine).[6] It is ambiguous why severe maternal morbidity and life-threatening complications are escalating; however, changes in the overall healthcare of women of reproductive age may contribute to the mentioned condition; to name a few, advanced maternal age, pre-pregnancy obesity, chronic diseases prior to pregnancy, and cesarean section.[7] Conversely, advancements in medical care, especially for women with chronic diseases, have also increased high-risk pregnancies in recent years.[8]

Pregnancy and life-threatening complications both together could cause physical and psychological distress, leading to post-traumatic stress disorder (PTSD); as a result, it makes women prone to postpartum psychiatric disorders, which may have long-lasting detrimental effects.[9] In a study conducted by Abdollahpour et al., it was found that many near-miss mothers mostly asked for the support and attention of healthcare providers during and after hospitalization. Most mothers responded to the adverse events with emotional and psychological reactions such as anxiety, grief, and anger. According to the mentioned study, the consequences of these events encompassed loss of life, miscarriage, and self-image, as well as diminished quality of life and marital dissatisfaction.[10] Improving the health of near-miss mothers appears to be a crucial priority, given the high incidence of high-risk pregnancies and childbirths, as well as our government’s current fertility promotion policies. As a result, the present study aimed to explore the factors related to depression, anxiety, and stress in near-miss mothers.

Materials and Methods

Study design and setting

This was a descriptive-analytical study, and the data were collected cross-sectionally. The study population consisted of near-miss mothers who had given birth one year before the present study. The near-miss mothers were selected through the census method over one year from hospitals affiliated with the Isfahan University of Medical Sciences. The data was collected using the DASS-21 (depression, anxiety, and stress) and a demographic questionnaire (personal, family, and fertility).

Study participants and sampling

Here are the inclusion criteria for the present study: Mothers who had experienced chronic complications during pregnancy, childbirth, and within 42 days of pregnancy termination and those who had at least one criterion of the clinical, laboratory, and management standard of the World Health Organization.[11] Clinical criteria consisted of acute cyanosis, gasping, respiratory rate over 40 per minute or <6 per minute, shock, oliguria unresponsive to diuretics or fluid therapy, coagulation disorders, a weak pulse of more than 12 hours (Glasgow Coma Score, <10), absence of pulse, stroke, continuous and uncontrollable seizure and complete paralysis, and pre-eclampsia with jaundice. Laboratory criteria were as follows: Oxygen saturation level below 90% for 60 minutes sharp or more than that, PH <1.7, PaO2/FiO2 <200 mmHg, lactate >5 mmol/L, creatinine >3.5 mg/dL, platelet count <50,000 μL, bilirubin above 6 mg/dL, loss of consciousness and presence of glucose and ketones in the urine. Lastly, management criteria were as follows: Constant use of vasopressor medications, intubation, and ventilation for 60 minutes and more than 60 minutes unrelated to anesthesia, hysterectomy due to bleeding and/or infection, dialysis due to acute kidney failure, blood transfusion equal or more than five units of red blood cells (RBT), and cardiopulmonary resuscitation (CPR). Mothers who were willing to participate in this research were required to meet specific criteria; they were not pregnant and had no history of known psychiatric disorders before their recent pregnancy, according to the SIB system. Additionally, they had not faced unexpected stressors such as the death of an immediate family member during pregnancy.

Data collection tool and technique

The data collection involved a thorough review of medical records and the completion of the questionnaires by near-miss mothers. The data collection tools comprised a demographic questionnaire that included personal, fertility, and maternal care-related inquiries, in addition to depression, anxiety, and stress scale (DASS-21).

DASS-21 was developed by Lovibond in 1995 and includes 21 items; it evaluates stress, anxiety, and depression using seven different questions for each of the three subscales. The items are scored on a Likert scale ranging from 0 (never) to (always). The severity of depression, anxiety, and stress is categorized as normal, mild, moderate, severe, and extremely severe. The reliability and validity of the DASS-21 have been confirmed by several studies.[12,13]

After granting approval from the Research Committee of Isfahan University of Medical Sciences, the researcher was given a letter of introduction by Isfahan University of Medical Sciences. The researcher visited the Treatment and Health Deputy of the province and hospitals, presenting the letter of introduction. Following that, based on the recorded information in the hospital, the files of near-miss mothers who had given birth over the last year were presented to the researcher; thereafter, only those who met the inclusion criteria were selected for the present research, and then all the files were thoroughly inspected. Eventually, the researcher contacted the qualifying mothers via phone call and briefly explained the study, inviting them to participate. The questionnaires were completed either in person at the healthcare centers while following all COVID-19 protocols or over the phone.

Ethical consideration

Ethical approval was granted from the Research Committee of Isfahan University of Medical Sciences with the ethics code of IR.MUI.RESEARCH.REC.1399.671. All the participants were assured that their anonymity and confidentiality would be preserved, and they were empowered to withdraw from the research at any time. Following their agreement to participate in the study, an informed consent form was also completed. Furthermore, all near-miss mothers were referred to a psychologist to be examined.

Result

The study was conducted on 160 near-miss mothers. However, six of them were excluded from the study: Two of them were unwilling to fill out the questionnaires, one due to the unwillingness of the husband, and three did not respond. Eventually, all the information gathered from the 154 participants was analyzed.

According to the results, near-miss mothers had a mean score of age 32.31 with a standard deviation of 5.51 years. In comparison, their husbands had a mean age and standard deviation of 36.34 and 5.92, respectively. Most mothers and their husbands had low education levels; most mothers and their husbands were housewives and self-employed, respectively. The majority of the mothers had no previous history of miscarriage, and their recent pregnancy was indeed desired. Tables 1-3 present the relationship between depression, anxiety, and stress with demographic characteristics, fertility characteristics, and maternal care conditions among near-miss mothers.

Table 1 Correlation of depression, anxiety, and stress with demographic characteristics among near-miss mothers

	Depression	Anxiety	Stress	
	Mean±SD	Test result	Mean±SD	Test result	Mean±SD	Test result	
Mother’s age	12.55±9.74	r=-0.06, P=0.468	11.19±8.22	r=-0.098, P=0.236	19.50±9.68	r=-0.033, P=0.699	
Husband’s age	12.55±9.74	r=-0.09, P=0.277	11.19±8.22	r=0.132, P=0.108	19.50±9.68	r=-0.068, P=0.422	
Number of mother’s siblings	12.55±9.74	r=0.044, P=0.600	11.19±8.22	r=0.003, P=0.967	19.50±9.68	r=0.049, P=0.561	
Mother’s birth rating	12.55±9.74	r=0.065, P=0.434	11.19±8.22	r=0.042, P=0.614	19.50±9.68	r=0.086, P=0.310	
Mother’s education level	
    Illiterate	16.25±9.64	F=0.746, P=0.526	18.22±5.60	F=2.773, P=0.044	21.25±6.58	F=1.329, P=0.267	
    Primary school	14.06±9.62		11.26±6.91		22.33±8.83		
    High school	12.02±9.48		11.30±9.09		18.96±10.33		
    University degree	11.84±10.42		9.65±7.30		17.94±9.58		
Husband’s education level	
    Illiterate	18.33±12.48	F=0.806, P=0.492	18.57±5.12	F=2.195, P=0.091	21.66±8.33	F=0.698, P=0.555	
    Primary school	12.06±7.56		9.86±5.80		21.00±8.20		
    High school	12.13±9.70		11.23±9.03		18.40±9.78		
    University degree	13.11±10.97		11.05±7.99		20.22±10.95		
Mother’s job	
    Housewives	12.81±9.81	F=1.405, P=0.238	11.32±8.28	F=0.149, P=0.700	19.71±9.78	F=1.001, P=0.319	
    Employed	8.00±7.37		10.00±6.19		15.66±7.08		
Husband’s job	
    Employed	9.46±9.98	F=1.93, P=0.126	8.22±6.13	F=2.357, P=0.074	16.61±10.09	F=2.550, P=0.058	
    Worker	13.65±8.22		12.69±8.58		22.20±7.74		
    Self-employed	13.00±10.34		11.30±8.56		18.74±10.45		
    Jobless	20.00±12.43		16.50±3.41		24.00±10.06		
Place of living	
    City	12.89±9.65	F=0.728, P=0.395	11.15±8.30	F=0.016, P=0.898	19.66±9.27	F=0.167, P=0.684	
    Village	11.14±10.36		11.37±8.16		18.81±11.58		
Economic situation	
    Income less than expenses	13.45±9.93	F=3.392, P=0.068	11.87±8.72	F=2.693, P=0.103	20.45±10.05	F=2.380, P=0.125	
    Income equal to expenses	10.53±8.62		9.65±7.19		17.90±9.14		
    Income more than expenses	0.00±0.00		0.00±0.00		0.00±0.00		
Social support	
    Yes	11.33±8.65	F=22.459, P=0.000	10.39±7.42	F=18.99, P=0.000	19.01±9.45	F=1.660, P=0.200	
    No	23.84±12.68		20.30±11.27		22.90±11.50		

Table 2 Correlation of depression, anxiety, and stress with fertility characteristics among near-miss mothers.

	Depression	Anxiety	Stress	
	Mean±SD	Test result	Mean±SD	Test result	Mean±SD	Test result	
Number of pregnancies	12.55±9.74	r=0.043, P=0.605	11.19±8.22	r=0.004, P=0.958	19.5±9.68	r=0.074, P=0.381	
Number of deliveries	12.55±9.74	r=-0.028, P=0.733	11.19±8.22	r=-0.088, P=0.290	19.5±9.68	r=0.051, P=0.543	
Number of live children	12.55±9.74	r=-0.098, P=0.237	11.19±8.22	r=-0.134, P=0.104	19.5±9.68	r=-0.057, P=0.504	
Number of dead children	12.55±9.74	r=0.125, P=0.144	11.19±8.22	r=0.106, P=0.215	19.5±9.68	r=0.153, P=0.077	
Pregnancy age in the current delivery	12.55±9.74	r=-0.057, P=0.495	11.19±8.22	r=-0.103, P=0.216	19.5±9.68	r=-0.101, P=0.232	
Newborn weight	12.55±9.74	r=-0.084, P=0.320	11.19±8.22	r=-0.145, P=0.081	19.5±9.68	r=-0.128, P=0.133	
Apgar at birth	12.55±9.74	r=-0.033, P=0.698	11.19±8.22	r=0.026, P=0.765	19.5±9.68	r=-0.052, P=0.554	
History of abortion	
   Yes	13.61±10.37	F=0.428, P=0.514	12.31±8.79	F=0.888, P=0.348	20.92±10.59	F=0.917, P=0.340	
   No	12.44±9.55		10.90±8.03		19.18±9.34		
Marital Satisfaction	
   Yes	11.82±8.59	F=4.225, P=0.042	10.93±7.70	F=0.889, P=0.347	19.12±8.91	F=0.783, P=0.378	
   No	16.77±14.95		12.84±11.39		21.37±14.02		
Domestic violence	
   Yes	20.18±12.72	F=7.183, P=0.008	17.66±9.82	F=8/116, P=0.005	23.27±10.92	F=1.686, P=0.196	
   No	12.10±9.31		10.72±7.92		19.34±9.52		
Method of the last delivery	
   NVD	14.22±11.61	F=0.581, P=0.447	11.57±8.80	F=0.039, P=0.844	20.73±11.13	F=0.352, P=0.554	
   Cesarean	12.34±9.52		11.17±8.19		19.31±9.47		
Desired last pregnancy	
   Yes	12.07±9.90	F=1.042, P=0.309	10.78±8.62	F=0.987, P=0.322	18.26±9.38	F=6.890, P=0.010	
   No	13.94±9.25		12.30±6.99		23.02±9.78		
History of infertility	
   Yes	13.66±9.05	F=0.114, P=0.737	16.92±8.02	F=6.584, P=0.012	16.72±8.68	F=1.126, P=0.290	
   No	12.67±9.84		10.91±8.07		19.95±9.74		
Pregnancy the result of infertility treatment	
   Yes	10.50±4.24	F=0.425, P=0.516	14.22±6.20	F=1.114, P=0.293	15.42±5.25	F=1.463, P=0.229	
   No	12.78±9.81		11.23±8.32		19.95±9.79		
Prevention method before last pregnancy	
   Withdrawal	11.82±8.28	F=1.174, P=0.330	11.01±8.23	F=1.080, P=0.378	19.89±8.98	F=0.644, P=0.667	
   Ocp	14.50±14.17		12.50±5.74		21.00±11.48		
   IUD	5.00±7.07		9.00±7.07		11.00±15.55		
   Condom	11.66±5.98		8.66±5.31		22.00±7.34		
   Ampol	14.00±0.00		20.00±0.00		24.00±5.65		
   No method	17.50±10.68		14.66±8.41		21.83±7.30		
Sex of fetus in the last delivery	
   Boy	12.22±8.85	F=0.005, P=0.942	11.28±7.47	F=0.328, P=0.568	30.02±9.41	F=0.699, P=0.405	
   Girl	12.34±10.85		10.50±8.77		18.62±10.24		
The status of the child from the current delivery	
   Healthy	12.11±10.32	F=1.769, P=0.110	10.47±8.32	F=1.943, P=0.078	18.56±10.33	F=0.782, P=0.586	
   Preterm birth	11.76±8.85		11.23±7.92		19.76±9.32		
   Hypoxy	13.00±1.41		9.00±4.24		26.00±2.82		
   Dead birthday	22.00±10.58		18.72±10.16		24.00±6.59		
   Hospitalization	10.28±4.68		8.75±4.89		17.50±8.92		
   Neonatal death	12.33±10.68		11.33±6.77		22.80±13.08		
History and type of complication in previous pregnancies	
   No complications	12.46±9.38	F=0.673, P=0.134	11.06±8.21	F=0.362, P=0.236	19.59±9.54	F=1.357, P=0.239	
   genetic	0.00±0.00		0.00±0.00		0.00±0.00		
   blood pressure	11.00±7.34		8.00±4.16		16.00±9.12		
   Preterm delivery	16.66±13.31		11.33±9.45		24.00±15.62		
   diabetes	16.66±17.47		16.66±9.23		20.66±9.01		
   Kidney	34.00±0.00		20.00±0.00		34.00±0.00		
   heart	1.00±1.41		0.00±0.00		6.00±5.65		
   coronavirus	4.00±0.00		4.00±0.00		26.00±0.00		
The type of complication in the last pregnancy	
   No complications	0.00±0.00	F=1.845, P=0.074	0.00±0.00	F=2.393, P=0.019	0.00±0.00	F=2.150, P=0.036	
   severe corona	12.87±10.45		12.15±9.85		19.05±9.77		
   Postpartum bleeding	13.28±9.84		10.85±7.39		29.60±6.06		
   Heart	12.28±6.47		20.00±6.92		20.90±9.03		
   Platelet disorder	9.11±6.86		8.44±4.55		20.28±6.77		
   Embolism	21.00±0.00		14.33±0.00		12.75±0.00		
   Kidney	21.00±0.00		12.33±0.00		13.75±0.00		
   Hysterectomy	11.75±10.24		10.23±7.96		18.25±12.26		
   Pre-eclampsia, eclampsia, HELLP syndrome	8.18±6.60		6.90±6.41		18.54±9.03		
   Bleeding in pregnancy	28.00±0.00		22.00±0.00		32.00±0.00		

Table 3 Correlation of depression, anxiety, and stress scores with maternal care conditions among near-miss mothers

	Depression	Anxiety	Stress	
	Mean±SD	Test result	Mean±SD	Test result	Mean±SD	Test result	
Care according to the national program	
   Yes	12.20±9.47	F=8.194, P=0.005	11.14±8.14	F=1.987, P=0.161	19.37±9.57	F=2.806, P=0.096	
   No	26.00±10.70		17.00±10.13		28.66±2.30		
Care in the health sector	
   Yes	11.64±9.09	F=5.380, P=0.022	11.02±8.35	F=0.429, P=0.513	18.79±9.40	F=5.361, P=0.022	
   No	16.26±11.46		12.13±7.10		23.48±9.35		
Care in the private sector	
   Yes	12.21±9.46	F=2.026, P=0.157	11.03±8.06	F=0.430, P=0.513	19.49±9.63	F=0.013, P=0.908	
   No	16.14±12.73		12.57±10.47		19.83±11.36		
Pregnancy care agent in the health sector	
   Behvarz	11.38±11.61	F=0.358, P=0.699	11.38±10.01	F=0.276, P=0.759	18.83±8.88	F=0.370, P=0.691	
   Health care	8.00±8.48		7.00±4.24		14.00±11.31		
   Midwife	12.89±9.74		11.56±8.48		19.74±9.91		
Pregnancy care agent in the private sector	
   Midwife	0.00±0.00	F=1.626, P=0.205	0.00±0.00	F=0.128, P=0.722	0.00±0.00	F=2.039, P=0.156	
   General practitioner	0.00±0.00		8.00±0.00		6.00±0.00		
   Gynecologist	12.40±9.68		10.96±8.26		19.81±9.62		
Hospital of admission	
   First level	28.00±0.00	F=1.358, P=0.260	8.00±0.00	F=0.305, P=0.737	40.00±0.00	F=2.736, P=0.068	
   Second level	13.20±12.29		13.60±9.73		22.80±14.60		
   Third level	12.24±9.50		11.02±8.21		19.05±9.33		
Week of starting the first care in pregnancy	12.55±9.74	r=0.224, P=0.007	11.19±8.22	r=0.118, P=0.152	19.50±9.68	r=0.226, P=0.007	
Number of care during pregnancy	12.55±9.74	r=-0.080, P=0.365	11.19±8.22	r=0.020, P=0.817	19.50±9.68	r=0.024, P=0.785	
The number of prenatal care in the health sector	12.55±9.74	r=0.021, P=0.802	11.19±8.22	r=0.065, P=0.441	19.50±9.68	r=0.015, P=0.866	
Duration of hospitalization after complications	12.55±9.74	r=0.070, P=0.412	11.19±8.22	r=0.235, P=0.005	19.50±9.68	r=0.095, P=0.270	

Discussion

In the present study, the depression, anxiety, and stress of 154 near-miss mothers were examined using the DASS-21. The findings indicated a meaningful relationship between the mean score of depression of near-miss mothers and social support, and mothers who had no social support experienced higher levels of depression. A study conducted by Silva (2017) on the severe morbidity of maternal trauma and its relationship with social support showed that severe maternal morbidity occurred most often in individuals with low education levels, living in suburban areas, unemployed, alcohol users, and of higher age. In addition to that, many of these mothers were dissatisfied with long-term hospitalization, losing personal life, lack of independence, and difficulties in performing maternal tasks. According to the findings of this study, severe morbidity makes mothers emotionally and mentally vulnerable, which can lead to PTSD. Lack of enough social support could adversely affect mothers, both physically and mentally. It is evident that social support and family support are of great importance in maintaining mental health and coping with stressful situations.[14]

Additionally, the findings suggested that there is a significant relationship between the mean score of anxiety in near-miss mothers with their levels of education and social support; therefore, significantly higher anxiety was observed in mothers with low levels of education and lack of social support. Cardwell et al. (2013) identified these factors as determinants of stress during pregnancy: Socioeconomic status, employment status, level of education, access to prenatal care, drug abuse, ethnicity, cultural background, and quality of relationships with spouse and parents.[15] Omidvar et al. investigated the relationship between depression and some demographic variables. A significant association was found between depression and the individual’s education, employment status, satisfaction of spousal, family, and social support, the education level of the spouse, concerns regarding the cost of childbirth, the occurrence of a stressful event or trauma during or prior to pregnancy, and finally martial conflicts.[16] According to the findings of the present study, there is a significant association between social support and mothers’ depression which is in line with the findings of the previous studies. Therefore, there is a need for longer-term support for mothers in order to prevent depression. Other studies also indicated that social support decreases depression, which again aligns with the current study’s results.

Moreover, the research findings indicated a history of infertility, desired pregnancy, satisfaction with marital life, and the current pregnancy complication is linked to the mental health of near-miss mothers. Correspondingly, depression was higher in mothers who had experienced domestic violence and those unsatisfied with their marital life. In addition, the stress level was higher in mothers who had an unintended pregnancy recently. On the other hand, the current pregnancy complication was also associated with maternal stress; as mothers with the complication of postpartum hemorrhage experienced more stress. Additionally, the findings showed a meaningful relationship between the mean score of anxiety in near-miss mothers and domestic violence, the history of infertility, and the present complication; and near-miss mothers who had experienced domestic violence and infertility showed higher anxiety levels. The present complication in pregnancy was linked to the anxiety level; mothers who had heart complications and bleeding showed higher anxiety levels. In the study by Maryam Mahdavi et al. (2018), postpartum depression had no significant relationship with the rank of delivery, mode of delivery, and desired or unintended pregnancy.[17] According to a study conducted in Tabriz, 34.7% of mothers experienced postpartum depression, which had a significant association with job and place of living dissatisfaction, the unpleasant experience of pregnancy, unintended pregnancy, and high-stress levels.[18] Other studies identified factors including socioeconomic status, employment status, marital status, levels of education, access to antenatal care, drug abuse, cultural background, and the quality of relationship with the spouse and parents as determinants of stress during pregnancy.[15,19,20] Moreover, higher anxiety and depression in couples with a history of infertility have been reported.[21,22]

The findings of the study indicated that mothers who did not receive adequate antenatal care or did not receive care according to the national program showed a higher score of depression and stress. The study conducted by Lee et al. on 357 pregnant women showed that there is an association between depression during pregnancy and poor self-care during pregnancy, insecure attachment and delayed growth in the child, and postpartum depression.[23] The study by Rezaeian et al. reported an increase in stress and depression in women at risk of preterm labor resulting in decreased self-care behaviors. Hence, identifying and managing pregnant women prone to stress and depression and subsequently devising a plan to decrease depression and stress can enhance their level of self-care.[24] In their study titled “Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran,” Mohammadi et al. reported that the causes of near-miss experience and its subsequent complications among mothers of foreign nationalities were as follows: discrimination, delayed diagnoses, financial hardship, lack of health insurance, low literacy levels, inattentive healthcare providers.[25] To explain the reasoning behind these findings, it can be stated that antenatal care based on the national program results in improved maternal health and, consequently, a decrease in the levels of anxiety, stress, and depression.

Additionally, mothers’ follow-up appointments effectively identify pregnancies requiring special attention, high-risk pregnancies, and mental health problems. As a result, this leads to early identification of these mothers and necessary and timely interventions to reduce the complications. Moreover, mothers are provided with the necessary education during different weeks of pregnancy, the condition of the mother and fetus, nutrition education, pregnancy risk symptoms, and so on when receiving antenatal care. Receiving support from maternal healthcare providers and increasing maternal knowledge and awareness about pregnancy leads to an increase in self-confidence, consequently, a reduction in maternal stress, anxiety, and depression.

Conclusion

The findings indicated that lack of social support, domestic violence, and marital dissatisfaction leads to a significant increase in the mean score of depression among near-miss mothers. Additionally, an unemployed spouse, low level of education, lack of social support, unintended pregnancy, high blood pressure complications, and bleeding during pregnancy contribute to a significant increase in the mean score of stress among near-miss mothers. Furthermore, domestic violence, infertility history, and experiencing heart and bleeding complications significantly enhance anxiety among near-miss mothers. As a result, it is crucial to provide the necessary support to this vulnerable group of mothers to reintegrate them into normal living long after childbirth and discharge.

Financial support and sponsorship

Research Council of Isfahan University of Medical Sciences.

Conflicts of interest

Nil.

Acknowledgement

We would like to thank the Vice Chancellor of Research for Isfahan University of Medical Sciences for approving this research project and paying its budget, and all those who helped us in this research.
==== Refs
1 Naderi T Foroodnia S Omidi S Samadani F Nakhaee N Incidence and correlates of maternal near miss in Southeast Iran Int J Reprod Med 2015 2015 914713 25763409
2 Rodrigues PB Zambaldi CF Cantilino A Sougey EB Special features of high-risk pregnancies as factors in development of mental distress: A review Trends Psychiatry Psychother 2016 38 136 40 27737308
3 Beigi M Bahreini S Valiani M Rahimi M Danesh-Shahraki A Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014 Iran J Nurs Midwifery Res 2015 20 315 21 26120330
4 Fathalizadeh Soheila Razi Mohseneh Factors affecting maternal mortality and its solution 2015 Available from: https://sid.ir/paper/929762/en
5 World Health Organization Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health 2011
6 Tura AK Trang TL van den Akker T van Roosmalen J Scherjon S Zwart J Applicability of the WHO maternal near miss tool in sub-Saharan Africa: A systematic review BMC Pregnancy Childbirth 2019 19 79 30808325
7 Alina A Luke Kristine Huang Lindley Kathryn J. Carter Ebony B. Maddox Karen E. Joynt Severe Maternal Morbidity, Race, and Rurality: Trends Using the National Inpatient Sample, 2012–2017 Journal of Women’s Health Jun 2021 837 847 http://doi.org/10.1089/jwh.2020.8606
8 Dzakpasu S Deb-Rinker P Arbour L Darling EK Kramer MS Liu S Severe maternal morbidity in Canada: Temporal trends and regional variations, 2003–2016 J Obstet Gynaecol Can 2019 41 1589 98 31060985
9 Angelini CR Pacagnella RC Parpinelli MA Silveira C Andreucci CB Ferreira EC Quality of life after an episode of severe maternal morbidity: Evidence from a cohort study in Brazil Biomed Res Int 2018 2018 1 10 https://doi.org/10.1155/2018/9348647
10 Abdollahpour S Heidarian Miri H Khadivzadeh T The global prevalence of maternal near miss: A systematic review and meta-analysis Health Promot Perspect 2019 9 255 62 31777704
11 Say L Souza JP Pattinson RC WHO working group on maternal mortality and morbidity classifications Maternal near miss--towards a standard tool for monitoring quality of maternal health care Best Pract Res Clin Obstet Gynaecol 2009 23 287 96 19303368
12 Lovibond PF Lovibond SH The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories Behav Res Ther 1995 33 335 43 7726811
13 Sahebi A Asghari MJ Salari RS Validation of depression anxiety and stress scale (DASS-21) for an Iranian population Iranian Psychologists 2005 4 299 313
14 Silveira MS Gurgel RQ Barreto ÍDC Galvão LPL Vargas MM Severe maternal morbidity: Post-traumatic suffering and social support Rev Bras Enferm 2018 71 Suppl 5 2139 45 30365776
15 Cardwell MS Stress: Pregnancy considerations Obstet Gynecol Surv 2013 68 119 29 23417218
16 Omidvar S Kheirkhah F Azimi H Depression during pregnancy and its related factors Hormozgan Med J 2007 11 213 9
17 Mahdavy M Kheirabadi G The prevalence of postpartum depression and its related factors among women in Natanz City in 2018 (Iran) Qom Univ Med Sci J 2020 14 78 85
18 Sehhatie shafaei F Ranjbar koochaksariie F Ghojazadeh M Mohamadrezaei Z Study of Relationship between Some Predisposing Factors and Postpartum Depression J Ardabil Univ Med Sci 2008 8 1 54 61
19 Akbarian Z Kohan S Nasiri H Ehsanpour S The effects of mental health training program on stress, anxiety, and depression during pregnancy Iran J Nurs Midwifery Res 2018 23 93 7 29628955
20 Bina R Mohammadi F Kohan S Heidari Z Assessing the level of coronavirus disease anxiety and its related factors in third-trimester pregnant women referring to the health centers of Isfahan during the pandemic Int J Pediatr 2022 10 16058 67
21 De Berardis D Mazza M Marini S Del Nibletto L Serroni N Pino MC Psychopathology, emotional aspects and psychological counselling in infertility: A review Clin Ter 2014 165 163 9 24999571
22 Chehreh H Neisani Samani L Seyedfatemi N Hosseini AF Anxiety and its relationship with infertility and obstetrics factors in ART pregnant women Iran J Nurs 2012 25 77 84
23 Lee AM Lam SK Sze Mun Lau SM Chong CS Chui HW Fong DY Prevalence, course, and risk factors for antenatal anxiety and depression Obstet Gynecol 2007 110 1102 12 17978126
24 Rezaeian SM Abedian Z Roodsari RL Mazloom SR Dadgar S The relationship of prenatal self-care behaviors with stress, anxiety and depression in women at risk of preterm delivery Iran J Obstet Gynecol Infertil 2017 20 68 76
25 Mohammadi S Carlbom A Taheripanah R Essén B Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: A qualitative interview study Int J Equity Health 2017 16 121 28687082
