Abstract
Background
Antenatal depression is the most prevalent pregnancy‐associated mental health disorder. Previous studies have identified several risk factors for antenatal depression, including partner support. However, during the COVID‐19 pandemic, many relationship dynamics changed. This study examined the extent to which relationship factors had an impact on antenatal depression in comparison with other well‐researched factors in the context of the pandemic.
Methods
A secondary analysis was conducted using data from the P3 Cohort in Calgary, a longitudinal cohort study based in Alberta, Canada. Pregnant people (n = 872) completed self‐report questionnaires and validated scales about sociodemographic, psychological, and relationship characteristics. Antenatal depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). Logistic regression was used to assess the impact of reported characteristics on antenatal depression. Tests of model fit were used to examine whether the inclusion of variables related to relationship quality improved model fit after accounting for other known risk factors.
Results
Overall, 18.23% of participants experienced antenatal depression. Relationship factors including relationship unhappiness (OR = 1.98 [95% CI: 1.06–3.69]), having an upsetting partner (OR = 2.00 [95% CI: 1.17–3.40]), and having a lower quality of relationships with close friends and family (OR = 1.76 [95% CI: 1.14–2.73]) were associated with antenatal depression; however, inclusion of these relationship factors did not improve model fit after accounting for other known predictors.
Conclusion
Overall, relationship factors were not associated with antenatal depression during the pandemic after accounting for other known risk factors. Stress and anxiety caused by the pandemic may have overshadowed the impact of relationship factors, or relationship factors may have contributed to higher levels of stress and anxiety more generally within our sample.
Keywords: antenatal depression, COVID‐19, pregnancy, relationship, social support
1. INTRODUCTION
Antenatal depression is the most prevalent pregnancy‐associated mental disorder, affecting approximately 20% of pregnant people globally. 1 Antenatal depression is often associated with negative outcomes for pregnant people, their infants, and their families. Several well‐researched characteristics in a pregnant person's life contribute to their risk of developing antenatal depression, including sociodemographic, obstetric, and psychological characteristics. 2 In particular, social support and relationships have been shown to be important contributors to antenatal depression. 2 Specifically, partners are often a pregnant person's primary means of social support 3 ; however, relationship dynamics often change during pregnancy with pregnant people becoming more dependent on their partners for emotional and financial support. 3 These changes can create tension within a relationship which in turn can lead to a decrease in relationship satisfaction and the perceived level of relationship quality, 3 placing pregnant people at a greater risk of developing antenatal depression. 2 Pregnant people and partners who are best able to adapt to the demands of pregnancy‐related stress are less likely to see a decrease in the quality of their relationship and level of relationship satisfaction. 3
The importance of partner support was heightened during the COVID‐19 pandemic, especially during periods of lockdown when individuals were advised to work from home and limit their social contacts. 4 Consequently, partners had to rely on each other for support more than ever before, which led to changes in interdependence and relationship dynamics. 4 , 5 While this was a positive experience for many couples who were able to strengthen their relationship as a result of the increased amount of time spent together, 6 other couples suffered due to an exacerbation of pre‐existing problems in their relationship. 7
The rates of antenatal depression and anxiety rose dramatically during the pandemic, 8 , 9 which could be due to changes in relationship dynamics or stress surrounding the uncertainty of the pandemic. People who were pregnant during the pandemic were subjected to both pandemic‐related and pregnancy‐related stressors, which might have played an important role in increasing their risk of antenatal depression.
Given the stressful circumstances associated with both pregnancy and the pandemic, the importance of partner support during pregnancy was amplified during the COVID‐19 pandemic because usual social support networks were disrupted due to public health measures that restricted in‐person contact and prevented in‐person interactions with friends and extended family, in‐person prenatal classes, support groups, and other prenatal services. 4 , 10 Thus, relationship factors and partner support (or lack thereof) may have played a larger role in the development of antenatal depression than before the pandemic. This may not be reflected in previous studies examining this topic. Therefore, we sought to investigate the association between partner support and relationship factors on the occurrence of antenatal depression after accounting for other known risk factors in the context of the COVID‐19 pandemic.
2. MATERIALS AND METHODS
This study consisted of a secondary analysis of data from the P3 Cohort. The P3 Cohort is a prospective longitudinal pregnancy cohort study in Calgary, Alberta, Canada. Recruitment began in September 2021 and is ongoing. The P3 Cohort is comprised of five online surveys to be completed during pregnancy and the first year postpartum. Only data from the baseline survey conducted between September 2021 and January 2023 were used for the present study. Surveys were completed at <32 weeks gestation and the mean gestational age of survey completion was 18.2 weeks (SD = 7.6). Surveys collect comprehensive information about participants' physical, emotional, and mental health, demographic characteristics, relationships, sleep, and exercise. 11 For every completed survey, participants are compensated with a $10 electronic gift card. Participants are eligible for the P3 Cohort if they are <32 weeks pregnant with a singleton, living in the Calgary Zone of Alberta Health Services, and are ≥16 years old. Participants are recruited through social media and traditional methods including posters and postcards handed out by healthcare providers in the community. 12 As the focus of the present study is on relationship factors, only participants who reported having a partner were eligible. Ethics approval for the P3 Cohort overall (REB 20–1635) and for this sub‐study (REB 23–0050) was obtained from the University of Calgary Conjoint Health Research Ethics Board.
The outcome variable for this analysis was maternal antenatal depression, as assessed using the Edinburgh Postnatal Depression Scale (EPDS), a 10‐item scale that measures emotional and psychological distress during pregnancy. 13 The EPDS is one of the most‐used screening tools for antenatal and postnatal depression. Each item is expressed on a scale from 0 to 3, with a higher overall score indicating greater symptoms of depression. 14 We operationally defined antenatal depression as a score of 11 or higher on the EPDS, which is validated against diagnostic interviews to detect minor and major depression with a sensitivity of 81% and specificity of 88%. 15
Relationship factors are dynamic and affect multiple domains. As such, we measured several aspects of partner relationships, namely (1) relationship happiness, (2) primary person responsible for housework, (3) primary earner in the household, (4) partner support in the context of stressful situations using items adapted from the Social Relationships Index (SRI), 16 and (5) social support from close friends and family (assessed using the Quality of Relationships Inventory (QRI)). 17
Other known risk factors for antenatal depression that were evaluated in the present study included: demographic characteristics including age, education, country of origin, race, employment status, and annual household income; experiences of discrimination (assessed using the Everyday Discrimination Scale (short version) 18 ); history of mental health conditions; anxiety during pregnancy (assessed using the Patient‐Reported Outcomes Measurement Information System (PROMIS) anxiety short‐form 8a 19 ); general social support (assessed using the MOS Social Support Survey 6‐item scale (MOS‐SSS‐6) 20 ); and perceived stress (assessed using the Perceived Stress Scale (PSS) 21 ). It is important to note that general social support assessed by the MOS‐SSS‐6 differs from social support from close friends and family assessed by the QRI. The MOS‐SSS‐6 measures emotional support, informational support, tangible support, and positive social interactions on a global scale, whereas the QRI focuses on the social support provided by specific individuals and assesses the extent to which a relationship is positive and secure and the extent to which there is conflict present within a relationship.
2.1. Statistical analysis
Stata/BE 17.0 22 was used to carry out the statistical analyses. Bivariate analyses (using chi‐square and t‐tests for categorical and continuous variables, respectively) were conducted to compare the differences between participants with and without antenatal depression.
Logistic regression was used to estimate the odds of a woman having antenatal depression after adjusting for potential confounders. Three logistic regression models were used for this analysis. Model 1 included sociodemographic and psychological variables that were determined a priori because of their known association with antenatal depression in the literature. Therefore, all these variables were included in our final model (Model 3) regardless of statistical significance. Model 2 included only relationship‐related factors to determine their impact on antenatal depression when sociodemographic and psychological factors were not controlled for. This was an exploratory model because of the lack of consistency in the literature in terms of the number of relationship factors that are assessed when studying antenatal depression. As such, only significant factors from Model 2 were included in our final model (Model 3). Model 3 included all the factors from Model 1 and only the significant factors from Model 2.
A likelihood ratio test was conducted to compare the goodness of fit between Model 1 and Model 3. Additionally, the Akaike information criterion (AIC), Bayesian information criterion (BIC), and pseudo‐R 2 were used to evaluate and compare model fit. As likelihood‐ratio tests require nested models, a complete case analysis was required. Missing data were minimal and a comparison of those with and without missing data on each variable can be found in Appendix: Table A1.
3. RESULTS
At the time of this study, 972 pregnant people had been recruited into the P3 Cohort and completed the baseline questionnaire. A total of 953 (98.0%) people reported having a partner, and 872 of them (89.7%) had complete data on all variables and were included in this analysis. As seen in Table 1, most participants in our sample were White (75.0%), born in Canada (81.0%), graduated post‐secondary education (88.5%), working (85.0%), and had a household income greater or equal to $100,000 (76.0%).
TABLE 1.
Sociodemographic, psychological, and relationship characteristics of total sample and stratified for women with and without antenatal depression (n = 872).
| Total | Not Depressed: EPDS < 11 | Depressed: EPDS ≥ 11 | p‐Value | |
|---|---|---|---|---|
| n (%) | n (%, 95% CI) | n (%, 95% CI) | ||
| Sociodemographic factors | ||||
| Race | ||||
| White | 654 (75.0) | 544 (76.2, 73.0–79.3) | 110 (69.2, 61.6–75.9) | 0.061 |
| Other | 218 (25.0) | 169 (23.7, 20.7–27.0) | 49 (30.8, 24.1–38.4) | |
| Country of origin | ||||
| Born in Canada | 706 (81.0) | 581 (81.5, 78.5–84.2) | 125 (78.6, 71.6–84.3) | 0.404 |
| Other | 166 (19.0) | 132 (18.5, 15.8–21.5) | 34 (21.4, 15.7–28.4) | |
| Education | ||||
| Graduated post‐secondary | 772 (88.5) | 638 (89.5, 87.0–91.5) | 134 (84.3, 77.8–89.2) | 0.063 |
| Did not graduate post‐secondary | 100 (11.5) | 75 (10.5, 8.5–13.0) | 25 (15.7, 10.8–22.2) | |
| Employment status | ||||
| Working a | 741 (85.0) | 615 (86.3, 83.5–88.6) | 126 (79.2, 72.2–84.9) | 0.076 |
| Homemaker | 71 (8.1) | 54 (7.6, 5.8–9.8) | 17 (10.7, 6.7–16.5) | |
| Out of work | 60 (6.9) | 44 (6.2, 4.6–8.2) | 16 (10.1, 6.3–15.8) | |
| Annual household income | ||||
| <$100,000 | 209 (24.0) | 155 (21.7, 18.9–24.9) | 54 (34.0, 27.0–41.7) | 0.001** |
| ≥$100,000 | 663 (76.0) | 558 (78.3, 75.1–81.1) | 105 (66.0, 58.3–73.0) | |
| Experiences of discrimination | ||||
| No | 378 (43.4) | 340 (47.7, 44.0–51.4) | 38 (23.9, 17.9–31.1) | <0.001** |
| Yes | 494 (56.6) | 373 (52.3, 48.6–56.0) | 121 (76.1, 68.9–82.1) | |
| Age (Mean, SD) b | 32.6 (4.0) | 32.8 (4.7) | 30.8 (6.2) | <0.001** |
| Psychological factors | ||||
| History of mental health conditions | ||||
| No | 620 (71.1) | 543 (76.2, 72.9–79.1) | 77 (48.4, 40.7–56.2) | <0.001** |
| Yes | 252 (28.9) | 170 (23.8, 20.9–27.1) | 82 (51.6, 43.8–59.3) | |
| General social support | ||||
| Sufficient social support | 770 (88.3) | 642 (90.0, 87.6–92.0) | 128 (80.5, 73.6–85.9) | 0.001** |
| Insufficient social support | 102 (11.7) | 71 (10.0, 8.0–12.4) | 31 (19.5, 14.1–26.4) | |
| Anxiety during pregnancy (mean, SD) | 55.0 (7.9) | 53.0 (6.8) | 63.8 (5.8) | <0.001** |
| Stress (mean, SD) | 14.8 (6.1) | 13.3 (5.2) | 21.4 (5.3) | <0.001** |
| Relationship factors | ||||
| Relationship happiness | ||||
| Happy in relationship | 803 (92.1) | 669 (93.8, 91.8–95.4) | 134 (84.3, 77.8–89.2) | <0.001** |
| Unhappy in relationship | 69 (7.9) | 44 (6.2, 4.6–8.2) | 25 (15.7, 10.8–22.2) | |
| Primary person responsible for housework | ||||
| No | 312 (35.8) | 268 (37.6, 34.1–41.2) | 44 (27.7, 21.3–35.1) | 0.018* |
| Yes | 560 (64.2) | 445 (62.4, 58.8–65.9) | 115 (72.3, 64.9–78.7) | |
| Primary earner in household | ||||
| No | 634 (72.7) | 514 (72.1, 68.7–75.3) | 120 (75.5, 68.2–81.5) | 0.387 |
| Yes | 238 (27.3) | 199 (27.9, 24.7–31.3) | 39 (24.5, 18.5–31.8) | |
| How helpful is your partner to you? | ||||
| Very helpful to extremely helpful | 730 (83.7) | 609 (85.4, 82.6–87.8) | 121 (76.1, 82.6–87.8) | 0.004* |
| Moderately helpful to not helpful at all | 142 (16.3) | 104 (14.5, 12.2–17.4) | 38 (23.8, 17.9–31.1) | |
| How upsetting is your partner to you? | ||||
| A little upsetting to not upsetting at all | 725 (83.1) | 615 (86.3, 83.5–88.6) | 110 (69.2, 61.6–75.9) | <0.001** |
| Somewhat upsetting to extremely upsetting | 147 (16.9) | 98 (13.7, 11.4–16.5) | 49 (30.8, 24.1–38.4) | |
| How unpredictable is your partner to you? | ||||
| A little unpredictable to not unpredictable at all | 777 (89.1) | 645 (90.5, 88.1–92.4) | 132 (83.0, 76.4–88.1) | 0.006* |
| Somewhat unpredictable to extremely unpredictable | 95 (10.9) | 68 (9.5, 7.6–11.9) | 27 (17.0, 11.9–23.6) | |
| Quality of relationships with close friends and family | ||||
| Good | 724 (83.0) | 610 (85.6, 82.8–88.0) | 114 (71.7, 64.2–78.2) | <0.001** |
| Poor | 148 (17.0) | 103 (14.4, 12.0–17.2) | 45 (28.3, 21.8–35.8) | |
Abbreviation: CI, Confidence interval.
Working includes individuals working at a job, who are self‐employed, or students.
Age is based on a sample size of 519.
Significant at the 0.05 level (two‐tailed).
Significant at the 0.01 level (two‐tailed).
Most of our sample reported being happy in their relationship (92.1%). Most participants indicated that they were the primary person responsible for housework in their household (64.2%), but only around a quarter of participants indicated being the primary earner in their household (27.3%). In terms of partner support, most participants reported their partner as helpful in the context of stressful situations (83.7%), and not upsetting (83.1%) or unpredictable (89.1%) in the context of stressful situations. In addition, most participants reported having good‐quality relationships with their close friends and family (83.0%).
Participants with depression (18.23%) had a different sociodemographic profile from those who did not (Table 1). As it relates to relationship quality, participants with depressive symptoms were significantly more likely to report being unhappy in their relationships (15.7% vs. 6.2%, p < 0.001), their partners not being helpful to them (23.8% vs. 14.5%, p < 0.05), upsetting (30.8% vs. 13.7%, p < 0.001), and unpredictable (17.0% vs. 9.5%, p < 0.05) during stressful situations. Also, they reported having a poorer quality of relationships with their close friends and family (28.3% vs. 14.4%, p < 0.001).
As seen in Table 2, relationship unhappiness (aOR = 1.98 [95% CI: 1.06–3.69]), having a partner who is upsetting (aOR = 2.00 [95% CI: 1.17–3.40]), and having a lower quality of relationships with close friends and family (aOR = 1.76 [95% CI: 1.14–2.73]) all increased the odds of antenatal depression. However, after accounting for other known risk factors, only relationship unhappiness remained significant.
TABLE 2.
Logistic regression analysis of sociodemographic, psychological, and relationship factors to estimate the odds of a pregnant woman having antenatal depression (n = 872) and tests of model fit including the Akaike information criterion (AIC), Bayesian information criterion (BIC), and pseudo‐R 2.
| Dependent variable: antenatal depression (EPDS ≥ 10) | ||||||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | ||||
| aOR (95% CI OR) | p‐Value | aOR (95% CI OR) | p‐Value | aOR (95% CI OR) | p‐Value | |
| Sociodemographic factors | ||||||
| Race | ||||||
| White | ref | 0.099 | ref | 0.128 | ||
| Non‐white | 1.64 (0.91, 2.96) | 1.59 (0.87, 2.91) | ||||
| Country of origin | ||||||
| Born in Canada | ref | 0.869 | ref | 0.981 | ||
| Other | 0.95 (0.49, 1.84) | 1.01 (0.51, 1.98) | ||||
| Education | ||||||
| Graduated post‐secondary | ref | 0.081 | ref | 0.065 | ||
| Did not graduate post‐secondary | 0.52 (0.25, 1.08) | 0.50 (0.24, 1.05) | ||||
| Work activity—homemaker | 1.50 (0.66, 3.40) | 0.336 | 1.64 (0.72, 3.77) | 0.241 | ||
| Work activity—out of work | 0.84 (0.38, 1.83) | 0.656 | 0.82 (0.37, 1.81) | 0.617 | ||
| Income | ||||||
| ≥$100,000 | ref | 0.716 | ref | 0.745 | ||
| <$100,000 | 1.11 (0.64, 1.90) | 1.09 (0.63, 1.89) | ||||
| Experiences of discrimination | ||||||
| No experiences of discrimination | ref | 0.190 | ref | 0.141 | ||
| Experiences of discrimination | 1.41 (0.84, 2.35) | 1.48 (0.88, 2.48) | ||||
| Psychological factors | ||||||
| General social support | ||||||
| Sufficient social support | ref | 0.461 | ref | 0.803 | ||
| Insufficient social support | 1.27 (0.68, 2.37) | 0.91 (0.44, 1.88) | ||||
| History of mental health conditions | ||||||
| No history of mental health conditions | ref | 0.092 | ref | 0.094 | ||
| History of mental health conditions | 1.54 (0.93, 2.54) | 1.54 (0.93, 2.54) | ||||
| Anxiety during pregnancy (continuous) | ||||||
| Not anxious | ref | <0.001** | ref | <0.001** | ||
| Anxious | 1.23 (1.17, 1.30) | 1.23 (1.17, 1.30) | ||||
| Stress (continuous) | ||||||
| Not stressed | ref | <0.001** | ref | <0.001** | ||
| Stressed | 1.16 (1.10, 1.23) | 1.17 (1.10, 1.24) | ||||
| Model 1 | Model 2 | Model 3 | ||||
|---|---|---|---|---|---|---|
| OR (95% CI OR) | p‐Value | OR (95% CI OR) | p‐Value | OR (95% CI OR) | p‐Value | |
| Relationship factors | ||||||
| Relationship happiness | ||||||
| Happy | ref | 0.031* | ref | 0.043* | ||
| Unhappy | 1.98 (1.06, 3.69) | 2.19 (1.03, 4.67) | ||||
| Primary person responsible for housework | ||||||
| No | ref | 0.089 | ||||
| Yes | 1.41 (0.95, 2.08) | |||||
| Primary earner | ||||||
| No | ref | 0.498 | ||||
| Yes | 0.87 (0.58, 1.31) | |||||
| How helpful is your partner to you? | ||||||
| Helpful | ref | 0.612 | ||||
| Not helpful | 0.87 (0.50, 1.50) | |||||
| How upsetting is your partner to you? | ||||||
| Not upsetting | ref | 0.011* | ref | 0.395 | ||
| Upsetting | 2.00 (1.17, 3.40) | 1.30 (0.71, 2.40) | ||||
| How unpredictable is your partner to you? | ||||||
| Not unpredictable | ref | 0.984 | ||||
| Unpredictable | 1.01 (0.57, 1.31) | |||||
| Quality of relationships with close friends and family | ||||||
| Good | ref | 0.011* | ref | 0.405 | ||
| Poor | 1.76 (1.14, 2.73) | 0.78 (0.43, 1.40) | ||||
| Tests of model fit | ||||||
| Akaike information criterion (AIC) | 497.77 | 805.66 | 497.82 | |||
| Bayesian information criterion (BIC) | 555.02 | 843.83 | 569.38 | |||
| Pseudo‐R 2 (%) | 42.80 | 4.66 | 43.52 | |||
Abbreviations: CI, Confidence Interval; OR, Odds Ratio.
Significant at the 0.05 level (two‐tailed).
Significant at the 0.01 level (two‐tailed).
The likelihood‐ratio test indicated that Model 1 was better at estimating the odds of antenatal depression than Model 3 (χ 2(3) = 5.95, p = 0.114). This improved model fit was further supported by slightly lower AIC, lower BIC, and pseudo‐R 2 for Model 1 (Table 2).
4. DISCUSSION
This study aimed to examine the impact of relationship factors on antenatal depression in the context of the COVID‐19 pandemic compared with the impact of well‐researched predictors of antenatal depression (i.e., sociodemographic, obstetric, and psychological factors). While we observed clear differences in how relationships seemed to be functioning between pregnant people with and without antenatal depression, overall, our data suggest that relationship factors were not the main drivers of antenatal depression during the pandemic. Instead, sociodemographic and psychological factors had a greater impact on antenatal depression.
Although our second model did reveal that some relationship factors were significant when accounting for relationship‐related confounders, our third logistic regression model revealed that only relationship happiness was significantly associated with antenatal depression when accounting for potential confounding sociodemographic and psychological factors. The lack of significant relationship factors in Model 3 may be because the significant effects of marital conflict and low social support present in Model 2 were captured by the stress and anxiety variables in Model 3. This is supported by the fact that many studies have found that increased marital conflict and decreased partner support do lead to higher levels of anxiety and stress, along with depression. 23 Furthermore, individuals experiencing anxiety are more likely to view their relationships in a negative light. 24 Alternatively, other stressors associated with pregnancy during the pandemic that were independent of relationships (i.e., financial stressors, concerns surrounding getting sick, limited access to in‐person healthcare, etc.) may have had a more salient effect on antenatal depression than some of the relationship factors that we explored in Model 2.
Our tests of model fit revealed that Model 1, which did not include relationship factors, was better at estimating the odds of antenatal depression than Model 3. This may be because the unprecedented nature of the COVID‐19 pandemic may have led to increased anxiety and stress which could have overshadowed the impact of relationship factors on the development of antenatal depression. It is likely that the stress and anxiety caused by concerns about family well‐being, economic uncertainty, social isolation, and the overall unpredictability associated with the pandemic 7 played a major role in the development of antenatal depression for many women. For instance, Vacaru et al. compared rates of antenatal depression and anxiety before and during the COVID‐19 pandemic and found that there was a significant increase in depression and anxiety between the two time points. 10 The increase in depression and anxiety was speculated to be related to (1) general worries about COVID‐19 (i.e., concerns about contracting the virus, and overall concerns about the unpredictability and uncertainty surrounding the pandemic), (2) financial worries associated with the pandemic, and (3) concerns surrounding social support. 10 Thus, it is possible that the anxiety and stress associated with the pandemic were dominant factors in the development of antenatal depression, and that the inclusion of relationship factors in Model 3 undermined this effect due to some of the relationship variables exhibiting collinearity with the anxiety and stress variables.
Although our study did not tease apart different sources of anxiety and stress, it is probable that concerns similar to those identified by Vacaru et al. contributed to the levels of anxiety and stress, and ultimately antenatal depression, within our sample. Also, it is possible that the three pandemic‐related concerns identified by Vacaru et al. were intertwined with relationship changes associated with the pandemic.
Unlike our study, other studies have found relationship factors to be important predictors of antenatal depression when adjusting for sociodemographic and psychological confounders. For instance, Luciano et al. found problematic partner relationships to be significantly associated with antenatal depression in a multiple regression model. 25 However, their study did not include as many parameters in their model as ours (specifically, they did not include current anxiety and stress) which may have affected the significance of certain relationship variables. 25 Additionally, some relationship factors, including domestic violence, have consistently been found to be associated with antenatal depression across several different studies. 2 , 26 Domestic violence rates increased during the pandemic, 27 which may have played a role in the rise in antenatal depression rates. This effect may not have been captured by our baseline survey since no data were collected on domestic violence. The exclusion of certain relationship factors known to be associated with antenatal depression from our analysis may provide an alternative explanation as to why the model without relationship factors was the best at estimating the odds of antenatal depression.
Our study has many strengths. To the best of our knowledge, this is the first study to examine the impact of relationship factors on antenatal depression in the context of the COVID‐19 pandemic in a sample of Canadian women. We used several validated scales in the baseline surveys, which provide an objective assessment of factors relevant to antenatal depression, allowing for a more robust and reliable analysis compared with the use of self‐report measures alone. In addition, there were minimal differences between characteristics for partners with complete data compared with those with missing data. Therefore, by performing a complete case analysis, our results were not greatly affected.
This study also has several limitations. Firstly, the cross‐sectional nature of this study makes it difficult to assess temporality. For instance, based on the available data, we need to be cautious in drawing conclusions on whether depression before pregnancy led to increased relationship problems, or if relationship problems before pregnancy gave rise to antenatal depression. Future work should focus on a longitudinal analysis of the factors that contribute to antenatal depression to see whether stress and anxiety continued to play such an important role in the development of antenatal depression with the increased availability of COVID‐19 vaccines and the removal of most pandemic‐related restrictions and to see how relationship dynamics may change throughout pregnancy. The P3 Cohort baseline survey is not all‐inclusive about factors that are known to be associated with antenatal depression, including tobacco, alcohol, and drug use during pregnancy, experiences of domestic violence, and a history of pregnancy complications. 2 , 26 In addition, our sample mainly comprises highly educated and higher‐income White women born in Canada, being common in prospective pregnancy cohort studies. 28 , 29 The relative homogeneity of our sample may limit the generalizability of our findings to pregnant people in more disadvantaged groups.
5. CONCLUSION
Overall, this study contributes to the broader maternal health literature by investigating the impact of relationship factors on antenatal depression during the COVID‐19 pandemic. While we expected that relationship factors would play a more prominent role in antenatal depression, particularly during the pandemic when couples became increasingly dependent on each other, this study does provide some unique insights on some other factors that contributed to high rates of depression during this time. The findings from this type of work could be applied to other crises (i.e., natural disasters and infectious disease outbreaks) as well as to other added stressful circumstances during pregnancy (i.e., illness or death in the family, job loss, etc.). Researchers and prenatal care providers alike should continue to examine the impact of contextual factors on antenatal depression over time, especially as we are in the process of exiting the pandemic, to ensure that pregnant women are receiving the best and most comprehensive prenatal care possible.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
The P3 Cohort Study was jointly funded by the Alberta Children's Hospital Foundation and the Calgary Health Foundation. We would also like to acknowledge the entire P3 Cohort team and participants for their contributions to this study.
TABLE A1.
Sociodemographic, psychological, and relationship characteristics of total sample and stratified for participants with complete data and with missing data.
| Total | Complete data | Missing data | p‐Value | |
|---|---|---|---|---|
| n (%) | n (%, 95% CI) | n (%, 95% CI) | ||
| Sociodemographic factors | ||||
| Race (n = 952) | ||||
| White | 709 (74.5) | 654 (75.0, 72.0–77.8) | 55 (68.8, 57.8, 77.9) | 0.220 |
| Other | 243 (25.5) | 160 (25.0, 22.2–28.0) | 25 (31.2, 22.1–42.2) | |
| Country of origin (n = 952) | ||||
| Born in Canada | 771 (81.0) | 706 (81.0, 78.2–83.4) | 65 (81.2, 71.2–88.4) | 0.950 |
| Other | 181 (19.0) | 166 (19.0, 16.6, 21.8) | 15 (18.8, 11.6–28.8) | |
| Education (n = 952) | ||||
| Graduated post‐secondary | 837 (87.9) | 772 (88.5, 86.2–90.5) | 65 (81.2, 71.2–88.4) | 0.056 |
| Did not graduate post‐secondary | 115 (12.1) | 100 (11.5, 9.5–13.8) | 15 (18.8, 11.6–28.8) | |
| Employment status (n = 953) | ||||
| Working | 806 (85.6) | 741 (85.0, 82.4–87.2) | 65 (80.2, 70.1–87.5) | 0.522 |
| Homemaker | 80 (8.4) | 71 (8.1, 6.5–10.2) | 9 (11.1, 5.9–20.0) | |
| Out of work | 67 (7.0) | 60 (6.9, 5.4–8.8) | 7 (8.6, 4.2–17.0) | |
| Annual household income (n = 948) | ||||
| <$100,000 | 230 (24.3) | 209 (24.0, 21.2–26.9) | 21 (27.6, 18.8–38.7) | 0.475 |
| ≥$100,000 | 718 (75.7) | 663 (76.0, 73.1–78.8) | 55 (72.4. 61.3–81.2) | |
| Experiences of discrimination (n = 953) | ||||
| No | 418 (43.9) | 378 (43.3, 40.1–46.7) | 40 (49.4, 38.7–60.1) | 0.295 |
| Yes | 535 (56.1) | 494 (56.7, 53.3–59.9) | 41 (50.6, 39.9–61.3) | |
| Age (Mean, SD) (n = 548) | 32.4 (5.07) | 32.4 (5.07) | 32.13 (5.10) | 0.763 |
| Psychological factors | ||||
| History of mental health conditions (n = 953) | ||||
| No | 686 (72.0) | 620 (71.1, 68.0–74.0) | 66 (81.5, 71.5–88.5) | 0.047 |
| Yes | 267 (28.0) | 252 (28.9, 26.0–32.0) | 15 (18.5, 11.5–28.5) | |
| General social support (n = 953) | ||||
| Sufficient social support | 839 (88.1) | 770 (88.3, 86.0–90.3) | 69 (85.2, 75.7–91.4) | 0.408 |
| Insufficient social support | 114 (11.9) | 102 (11.7, 9.7–14.0) | 12 (14.8, 8.6–24.3) | |
| Anxiety during pregnancy (mean, SD) (n = 908) | 54.9 (7.9) | 55.0 (7.9) | 52.2 (7.4) | 0.041 |
| Stress (mean, SD) (n = 945) | 14.7 (6.2) | 14.8 (6.1) | 14.3 (6.7) | 0.519 |
| Relationship factors | ||||
| Relationship happiness (n = 952) | ||||
| Happy in relationship | 875 (91.9) | 803 (92.1, 90.1–93.7) | 72 (90.0, 81.2–94.9) | 0.512 |
| Unhappy in relationship | 77 (8.1) | 69 (7.9, 6.3–9.9) | 8 (10.0, 5.1–18.8) | |
| Primary person responsible for housework | ||||
| No | 339 (35.8) | 312 (35.8, 32.7–39.0) | 27 (35.5, 25.6–46.9) | 0.965 |
| Yes | 609 (64.2) | 560 (64.2, 61.0–67.3) | 49 (64.5, 53.1–74.4) | |
| Primary earner in household (n = 949) | ||||
| No | 698 (73.6) | 634 (72.7, 69.6–75.6) | 64 (83.1, 73.0–89.9) | 0.047 |
| Yes | 251 (26.4) | 238 (27.3, 24.4–30.4) | 13 (16.9, 10.1–27.0) | |
| How helpful is your partner to you? (n = 949) | ||||
| Very helpful to extremely helpful | 158 (16.7) | 730 (83.7, 81.1–86.0) | 61 (79.2, 68.7–86.9) | 0.310 |
| Moderately helpful to not helpful at all | 791 (83.3) | 142 (16.3, 14.0–18.9) | 16 (20.8, 13.1–31.3) | |
| How upsetting is your partner to you? (n = 950) | ||||
| A little upsetting to not upsetting at all | 790 (83.2) | 725 (83.1, 80.5–85.5) | 65 (83.3, 73.4–90.1) | 0.966 |
| Somewhat upsetting to extremely upsetting | 160 (16.8) | 147 (16.9, 14.5–19.5) | 13 (16.7, 9.9–26.6) | |
| How unpredictable is your partner to you? (n = 946) | ||||
| A little unpredictable to not unpredictable at all | 843 (89.1) | 777 (89.1, 86.9–91.0) | 66 (89.2, 79.8–94.5) | 0.982 |
| Somewhat unpredictable to extremely unpredictable | 103 (10.9) | 95 (10.9, 9.0–13.1) | 8 (10.8, 5.5–20.2) | |
| Quality of relationships with close friends and family (n = 953) | ||||
| Good | 793 (83.2) | 724 (83.0, 80.4–85.4) | 69 (85.2, 75.7–91.4) | 0.619 |
| Poor | 160 (16.8) | 148 (17.0, 14.6–19.6) | 12 (14.8, 8.6–24.3) | |
| Depression (n = 953) | ||||
| Not depressed | 781 (82.0) | 713 (81.8, 79.1–84.2) | 68 (84.0, 74.3–90.5) | 0.625 |
| Depressed | 172 (18.0) | 159 (18.2, 15.8–20.9) | 15 (16.0, 9.5–25.7) | |
Pekarsky C, Skiffington J, Chaput K, Slater D, Leijser LM, Metcalfe A. The impact of relationship factors on antenatal depression in the context of the COVID‐19 pandemic. Birth. 2025;52:78‐88. doi: 10.1111/birt.12862
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.