The Relationship Between Health Literacy and Spiritual Well‐Being With Symptoms of Depression and Anxiety in Pregnant Women: A Descriptive‐Analytical Research

ABSTRACT

Aim

Among the key protective factors identified in reducing such psychological complications are health literacy and spiritual well‐being. This study aimed to examine the relationship between health literacy and spiritual well‐being with symptoms of depression and anxiety in pregnant women.

Design

A descriptive‐analytical study was planned.

Methods

The study was conducted on a convenience sample of 200 third‐trimester pregnant women attending prenatal clinics at teaching hospitals affiliated with Babol University of Medical Sciences, Iran, between January 2024 and July 2024. Data collection tools included validated questionnaires on health literacy, spiritual well‐being and the Brief Symptom Inventory‐18 (BSI‐18) to assess symptoms of depression and anxiety during the third trimester. Multivariate logistic regression was used to analyze the associations.

Results

Logistic regression analysis indicated that an ‘excellent’ level of health literacy was significantly associated with reduced odds of anxiety (OR = 0.209, p = 0.005) and depression (OR = 0.307, p = 0.027). Similarly, high spiritual well‐being showed a protective effect against both anxiety (OR = 0.296, p = 0.007) and depression (OR = 0.329, p = 0.009). Conversely, having a university‐level education was associated with increased likelihood of anxiety (OR = 4.512, p = 0.019). Based on the findings, it is recommended that nurses and health care providers implement educational programs to promote health literacy and strengthen spiritual health in prenatal care for women.

1. Introduction

Health literacy (HL) has been recognized as a global public health concern (Health Literacy, n.d.). HL refers to an individual's ability to acquire, interpret and understand basic health information and services necessary for making appropriate health decisions. It has been well‐established that many health disparities are associated with inadequate HL. HL encompasses the knowledge, motivation and competencies required to access, comprehend, evaluate and apply health‐related information within contexts of healthcare, disease prevention and health promotion. Poor HL can result in a lack of understanding about illness and personal well‐being, and has been identified as a stronger predictor of health outcomes than age, race, occupation, education or income (Zibellini et al. 2021). Cross‐sectional studies have shown that individuals with low HL often exhibit limited health knowledge, poor self‐management of chronic diseases, inadequate use of preventive services and overall poorer health status (Jafari et al. 2021).

Maternal HL is a critical concern for two main reasons. First, pregnancy may represent a woman's initial encounter with the healthcare system. Navigating this complex system for the first time can be overwhelming, even for those with adequate literacy skills. Women with limited HL are significantly more likely to experience difficulties in understanding new information and following medical guidance. Second, a woman's health status and her comprehension of health‐related information before, during and after pregnancy directly influence her child's development and well‐being. Given the vital role of maternal education in promoting child and family health, women have been identified as a primary target population for HL enhancement (Carbone et al. 2024; Jiregna et al. 2024). Limited HL remains a common issue among pregnant women receiving services at healthcare centers. Since inadequate HL can hinder proper understanding of medical messages and recommendations, it is essential for healthcare professionals to adopt effective communication strategies tailored to this population (Ghanbari et al. 2020).

Spiritual well‐being (SWB) is recognized as one of the more recently emphasized dimensions of health, alongside physical, psychological and social health. It refers to a sense of affirmation, positive emotions, ethical values and a meaningful connection with a higher power, others and oneself (Gomez 2025). Strengthening SWB contributes to greater adaptability, improved attitudes toward life, reduced stress and negative emotions, and an enhanced sense of autonomy and empowerment (Galderisi 2024). A positive relationship has been observed between faith and favourable mood states. Various studies have explored the factors influencing spiritual health (Khorasani et al. 2022). Although the definition and importance of SWB are widely acknowledged, spiritual care practices differ across cultures, ethnicities and nations, and individuals approach this concept based on their unique cultural and religious backgrounds (Aziato et al. 2016).

Pregnancy is commonly regarded as one of the most significant and vulnerable stages in a woman's life, characterized by profound physical and psychological changes. These changes often give rise to anxiety and worry, which, if left unmanaged, may lead to serious mental health issues such as postpartum depression and anxiety (Biaggi et al. 2016). Therefore, women require special psychological support during this time. Although human beings are holistic entities, comprising physical, psychological, social and spiritual aspects, no other period of life engages women as deeply with spirituality as pregnancy. This period necessitates attention to spiritual care (Bodaghi et al. 2017). While religious beliefs and practices can serve as powerful sources of comfort, hope and meaning, they may also be intricately intertwined with neurotic and psychotic symptoms (Lucchetti et al. 2021; VanderWeele and Ouyang 2025).

One of the key factors that can help mothers cope with the psychological challenges of pregnancy is HL. HL enables pregnant women to better understand information related to pregnancy and childbirth, allowing them to make more informed decisions regarding their own care and that of their infants (Ugurlu and Uctu 2023; Nawabi et al. 2021). However, many women particularly those living in underserved areas or with lower levels of education lack sufficient HL. This deficiency can impair their ability to follow medical recommendations and ultimately lead to increased physical and psychological complications (Uyanik et al. 2025; Kim et al. 2025).

In addition to HL, SWB also plays a crucial role in reducing anxiety and depression during pregnancy. SWB refers to an individual's connection to deeper meaning in life or spiritual beliefs, which can serve as a source of emotional relief and psychological support. Studies have shown that SWB helps expectant mothers feel more secure and better equipped to handle the stresses associated with pregnancy and childbirth. Numerous investigations have also linked inadequate spiritual literacy with higher rates of suicide, depression, anxiety, substance abuse and psychiatric disorders (Lucchetti et al. 2021). Addressing these issues and clarifying the concept of SWB in the context of pregnancy as well as implementing interventions to support this aspect of health represent essential steps in developing effective prenatal care programs (Narenji et al. 2018).

Limited evidence is available regarding the effects of HL and SWB in pregnant women. A systematic review found that HL is associated with pregnancy outcomes (Zibellini et al. 2021). Additional studies also support the association between SWB and pregnancy‐related outcomes (Tayebi et al. 2020). One study indicated that HL is positively related to the quality of prenatal care (Izadirad et al. 2018), and some findings suggest a link between HL and SWB in pregnant populations (Khorasani et al. 2022). Furthermore, HL has been inversely associated with psychological disorders among pregnant women, such as postpartum depression (Poreddi et al. 2021).

In Iran, where religious and spiritual beliefs play a significant role in everyday life, investigating the impact of SWB on maternal mental health and neonatal outcomes is of particular importance. Despite this cultural relevance, comprehensive research in this area remains scarce. Consequently, there is limited knowledge regarding the relationship between HL and SWB with symptoms of depression and anxiety in pregnant women. Therefore, the present study aimed to examine the associations between HL and SWB and maternal symptoms of depression and anxiety.

2. Materials and Methods

2.1. Participants and Procedure

This descriptive‐analytical study was conducted to investigate the relationship between HL and SWB with symptoms of depression and anxiety in pregnant women. A convenience sampling method was employed. The study population consisted of all pregnant women in their third trimester that enrolled in Babol Pregnancy Mental Health Registry from January 2024 to July 2024, Iran. The participants attended prenatal clinics affiliated with the teaching hospitals of Babol University of Medical Sciences (Rohani, Yahya Nejad and Marzikola Hospitals). The researcher was present at the clinics and invited eligible women to participate in the study. After screening for inclusion and exclusion criteria, participants were asked to complete three standardized questionnaires: the Health Literacy Questionnaire, the Spiritual Well‐Being Scale and the 18‐item Brief Symptom Inventory (BSI‐18).

The study protocol was approved by the Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.REC.1403.066). All participants were fully informed about the study's objectives and procedures and provided written informed consent prior to participation. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments (World Medical Association 2013).

Data were collected in private counselling rooms located within the prenatal clinics to ensure confidentiality and minimize distractions. After eligibility screening, participants received standardized instructions, and the questionnaires were primarily self‐administered using paper‐and‐pencil forms. For women who had difficulty reading or preferred assistance, a trained researcher read the items aloud and recorded their responses, while ensuring that partners or family members were not present during completion. Data were collected during the third trimester of pregnancy. The average duration of data collection per participant, including consent, instruction and completion of all questionnaires, was approximately 25–30 min.

Inclusion criteria were: age above 18 years, education level higher than elementary school (grade five), hemodynamic, physical, and psychological stability, and willingness to participate. Women with severe pregnancy‐related complications (e.g., preeclampsia requiring intensive management, placenta previa with active bleeding) or unstable chronic medical conditions were excluded, as were those with foetal loss during childbirth, lack of consent, self‐reported history of severe psychiatric disorders (e.g., bipolar disorder or psychosis), or incomplete questionnaire data. However, women with common, well‐controlled pregnancy conditions such as diet‐controlled gestational diabetes were not excluded.

2.2. Sample Size

The required sample size was determined based on the number of variables included in the logistic regression models. According to established guidelines suggesting a minimum of 10 events per variable (Peduzzi et al. 1996), and given that the primary models included up to seven independent variables, a sample of 200 pregnant women was deemed adequate.

2.3. Measures

2.3.1. Health Literacy Questionnaire

The Health Literacy Questionnaire used in this study was developed and validated by Montazeri et al. (2014). It consists of 33 items rated on a 5‐point Likert scale, resulting in a total score range from 33 to 165. The questionnaire assesses five key dimensions of health literacy: reading, access, comprehension, evaluation and decision‐making/behaviour. In this study, participants completed the questionnaire once during their pregnancy (Montazeri et al. 2014). The instrument has demonstrated good construct validity, with exploratory factor analysis explaining 53.2% of the variance, and internal consistency reliability with Cronbach's alpha coefficients ranging from 0.72 to 0.89.

2.3.2. Spiritual Well‐Being Scale (SWB)

The Spiritual Well‐Being Scale (SWB) was developed by Paloutzian and Ellison 1982. This scale consists of 20 items rated on a 6‐point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. The scale includes two subscales: Religious Well‐Being (odd‐numbered items) and Existential Well‐Being (even‐numbered items), with 10 items each. Each subscale contributes a maximum of 60 points, yielding a total score range between 20 and 120. For positively worded items, ‘strongly agree’ receives a score of 6 and ‘strongly disagree’ a score of 1; for negatively worded items, the scoring is reversed. Total scores are categorized as follows: low (20–40), moderate (41–99) and high (100–120) spiritual well‐being. The Persian version of the scale was validated by Abbasi et al. (2006) in a study on 283 nursing students from Tehran, Iran and Shahid Beheshti Universities, with a reported reliability coefficient of R = 0.82. In this study, the SWB scale was administered once during pregnancy (Abbasi et al. 2014).

2.3.3. Brief Symptom Inventory‐18 (BSI‐18)

The BSI‐18 is an 18‐item short form of the original Brief Symptom Inventory, designed to assess psychological distress. It includes three subscales: depression, anxiety and somatization, each consisting of 6 items. The total score, known as the Global Severity Index (GSI), ranges from 0 to 72, while each subscale ranges from 0 to 24. For women, the clinical cut‐off points are defined as follows: depression ≥ 4, anxiety ≥ 6, somatization ≥ 5 and GSI ≥ 13. The Persian version of the BSI‐18 has demonstrated good psychometric properties, with a validity coefficient of 0.81 and a reliability (Cronbach's alpha) of 0.90 (Akhavan Abiri and Shairi 2020).

2.4. Statistical Analyses

Data were analysed using IBM SPSS Statistics version 26.0 (IBM Corp., Released 2019, Armonk, NY, USA). Descriptive analyses were conducted using means and standard deviations for quantitative variables, and frequencies and proportions for qualitative variables. To examine bivariate associations, independent t‐tests and chi‐squared tests were employed. Multivariate logistic regression analysis was used to examine the variables associated with depression and anxiety symptoms. For these models, depression and anxiety symptoms were dichotomized using established clinical cut‐off points for women: depression ≥ 4 and anxiety ≥ 6 (Akhavan Abiri and Shairi 2020). The reference category for health literacy was ‘Not very sufficient’, and for spiritual well‐being was ‘Moderate’. Covariates entered into each model included maternal age, education level (dummy coded with Primary as reference), and employment status (dummy coded with Housewife as reference). A significance level of 0.05 was considered.

3. Results

As shown in Table 1, the mean age of participants was 31.01 ± 5.84 years. Regarding educational level, over 80% of the mothers had either secondary or university education and the majority (71%) were housewives. The mean total HL score in this sample was 133.35 ± 19.37. More than 70% of participants were categorized as having ‘sufficient’ or ‘excellent’ HL. Among the subdomains, the highest mean scores were observed in decision‐making (47.5 ± 7.64) and comprehension (30.4 ± 4.70). SWB was assessed as relatively favourable, with a mean total score of 94.28 ± 14.60. Approximately 42% of the participants were categorized as having ‘good’ SWB. In terms of psychological status, symptoms of depression and anxiety were observed in 26.5% and 21.5% of the women, respectively.

TABLE 1.

Descriptive statistics of the participants (n = 200).

Variable	Category/Unit	Mean ± SD	n (%)
Quantitative variables
Maternal age	Years	31.01 ± 5.84	—
Health literacy (total)		133.35 ± 19.37	—
	Reading	16.0 ± 3.39	—
	Access	24.4 ± 4.66	—
	Comprehension	30.4 ± 4.70	—
	Evaluation	15.1 ± 3.21	—
	Decision making	47.5 ± 7.64	—
Spiritual well‐being		94.28 ± 14.60	—
	Religious well‐being	48.9 ± 7.91	—
	Existential well‐being	45.3 ± 8.33	—
Gestational age	Weeks	37.54 ± 1.88	—
Categorical variables
Educational level	Primary	—	32 (16%)
	Intermediate	—	93 (46.5%)
	University	—	75 (37.5%)
Employment status	Housewife	—	142 (71%)
	Employed	—	52 (26%)
	Student	—	6 (3%)
Health literacy level	Insufficient	—	10 (5%)
	Not very sufficient	—	42 (21%)
	Sufficient	—	77 (38.5%)
	Excellent	—	71 (35.5%)
Spiritual health level	Moderate	—	117 (58.5%)
	Good	—	83 (41.5%)
Depression symptoms	Yes	—	53 (26.5%)
	No	—	147 (73.5%)
Anxiety symptoms	Yes	—	43 (21.5%)
	No	—	157 (78.5%)

Note: The cut‐off point for symptoms in each of the subscales is ≤ 4 for depression, ≤ 6 for anxiety, ≤ 5 for somatization and ≤ 13 for total score. The range of scores for the subscales of the Spiritual Health Questionnaire is: low spiritual health 20–40, medium spiritual health 41–99 and high spiritual health 120–100. The range of scores for the subscales of the Health Literacy Questionnaire is: insufficient 0–50, not very sufficient 50.1–66, sufficient 84–66.1 and excellent 84.1–100.

The associations between HL, SWB and demographic variables are presented in Table 2. One of the key findings of the study was the significant association between maternal age and both HL and SWB. Increased maternal age was associated with a higher likelihood of being classified in the ‘sufficient’ (OR = 1.073, p = 0.0277) and ‘excellent’ (OR = 1.093, p = 0.0106) HL groups, as well as in the ‘good’ SWB group (OR = 1.084, p = 0.002). These results suggest that older age may be linked to greater cognitive maturity and heightened awareness of health‐related issues.

TABLE 2.

The effect of demographic variables on health literacy and spiritual well‐being.

Variable	Group	Health literacy–sufficient (OR) [95% CI]	p	Health literacy–excellent (OR) [95% CI]	p	Spiritual health–good (OR) [95% CI]	p
Maternal age		1.073 [1.007–5.727]	0.0277	1.093 [1.020–4.449]	0.0106	1.084 [1.029–1.142]	0.002
Education	Intermediate vs. Primary	2.191 [0.838–5.727]	0.1096	1.545 [0.536–4.449]	0.4200	1.183 [0.505–2.771]	0.697
	University vs. Primary	3.831 [1.166–12.586]	0.0269	5.844 [1.736–19.667]	0.0043	1.454 [0.572–3.696]	0.4308
Employment status	Employed vs. Housewife	0.742 [0.270–2.041]	0.5644	1.392 [0.519–3.734]	0.5110	0.688 [0.327–1.446]	0.3244

Note: Health literacy at two levels: ‘Sufficient’ and ‘Excellent’, using ‘Not very sufficient’ as the reference category and spiritual health (categorized as ‘Good’ vs. ‘Moderate’).

University education was identified as a strong predictor of HL. Compared to women with primary‐level education, those with a university‐level education were significantly more likely to have sufficient (OR = 3.83, p = 0.0269) or excellent (OR = 5.84, p = 0.0043) HL. However, no significant relationship was found between educational level and SWB, indicating that SWB may be influenced more by personal, cultural or religious factors than by formal education.

Employment status was not significantly associated with any of the outcome variables. Although employed women tended to have higher HL scores (OR = 1.39), this difference was not statistically significant (p = 0.5110). Likewise, no significant association was observed between employment and SWB.

The results of the multivariate logistic regression analysis are presented in Table 3. Findings indicated that higher levels of HL and good SWB were significantly associated with a lower likelihood of experiencing anxiety among pregnant women. Participants with ‘excellent’ HL had 79% lower odds of experiencing anxiety compared to the reference group (Not very sufficient) (OR = 0.209, 95% CI: 0.066–0.602, p = 0.005). Similarly, participants with good spiritual well‐being demonstrated significantly reduced anxiety symptoms (OR = 0.296, 95% CI: 0.116–0.687, p = 0.007).

TABLE 3.

Results of multivariate logistic regression analysis for variables associated with anxiety symptoms.

Variable		Odds ratio (OR)	95% confidence interval	p
Spiritual health	(Good vs. Moderate)	0.296	0.116–0.687	0.007
Health literacy	(Sufficient vs. Not very sufficient)	0.639	0.264–1.532	0.316
	(Excellent vs. Not very sufficient)	0.209	0.066–0.602	0.005
Maternal age		1.009	0.944–1.093	0.785
Education	(Intermediate vs. Primary)	1.514	0.509–5.223	0.478
Education	(University vs. Primary)	4.512	1.368–17.418	0.019
Employment status	(Employed vs. Housewife)	0.483	0.179–1.216	0.133

Notably, having a university‐level education was associated with a significantly increased risk of anxiety (OR = 4.512, p = 0.019), which may reflect greater health awareness and concern within this population. Other variables such as maternal age, secondary education and employment status were not significantly associated with anxiety symptoms (p > 0.05).

In the depression prediction model (Table 4), both good SBW and higher levels of HL emerged as protective factors. Mothers with good SWB had a 67% lower likelihood of experiencing depressive symptoms compared to those with moderate SWB (OR = 0.329, 95% CI: 0.144–0.753, p = 0.009).

TABLE 4.

Results of multivariate logistic regression analysis for variables associated with depression symptoms.

Variable		Odds ratio (OR)	95% confidence interval	p
Spiritual health	(Good vs. Moderate)	0.329	0.144–0.753	0.009
Health literacy	(Sufficient vs. Not very sufficient)	0.418	0.176–0.988	0.047
	(Excellent vs. Not very sufficient)	0.307	0.108–0.872	0.027
Maternal age		1.046	0.987–1.109	0.124
Education	(Intermediate vs. Primary)	2.308	0.782–6.813	0.129
	(University vs. Primary)	2.034	0.696–5.941	0.194
Employment status	(Employed vs. Housewife)	0.774	0.322–1.858	0.564

Furthermore, both ‘sufficient’ and ‘excellent’ levels of HL were significantly associated with reduced odds of depression (OR = 0.418, p = 0.047 and OR = 0.307, p = 0.027, respectively). In contrast, maternal age, education level and employment status were not significantly associated with depressive symptoms, suggesting that psychological and cognitive variables, such as HL and spirituality, may play a more dominant role in the development of depression than purely demographic factors.

4. Discussion

This study examined the relationship between HL and SWB with symptoms of depression and anxiety in pregnant women and identified several modifiable factors that may help protect mental health during pregnancy. The findings largely converge with recent evidence, while some inconsistencies in the literature highlight the role of contextual and methodological differences.

The negative association observed between HL and depressive and anxiety symptoms in pregnant women suggests that women who better understand, interpret and use health information are more capable of managing pregnancy‐related stressors. HL enables pregnant women to comprehend medical recommendations, adhere to treatment plans and actively participate in decision‐making, which can reduce uncertainty and perceived threat and thereby alleviate emotional distress.

These findings suggest that health literacy (HL) plays an important role in pregnant women's psychological well‐being, although its effects may be both beneficial and context‐dependent. Women with higher HL are generally better able to obtain, understand and use health information, which can improve decision‐making, increase self‐efficacy, enhance use of healthcare services and reduce uncertainty and emotional distress. In this regard, our findings are consistent with previous studies showing a protective role of HL in maternal mental health. For instance, the results align with the study by Khorasani et al. (2022), which demonstrated that maternal HL has a direct impact on reducing depression and anxiety. Similarly, a study involving 281 primiparous women in Kabul found that lower HL was significantly associated with higher rates of postpartum depression (OR: 0.95, p = 0.0001) (Ezadi et al. 2021). In contrast, another study showed that awareness of postpartum depression among mothers was generally low and had no significant impact on their mental health (Poreddi et al. 2021). This discrepancy suggests that other contextual factors, such as cultural beliefs and social support systems, may also influence psychological well‐being and mitigate depressive symptoms during and after pregnancy.

However, the effect of HL is not necessarily uniform across all settings. Although better HL can help women manage pregnancy‐related concerns, greater awareness of possible complications may also increase worry, particularly when information is difficult to interpret or when access to support and care is limited. This may explain why Poreddi et al. (2021) found that awareness of postpartum depression did not significantly influence maternal mental health outcomes. Differences across studies may therefore reflect contextual factors such as culture, social support, healthcare access and differences in how HL is measured. In our study, the inverse association between HL and emotional distress may be because women with higher HL were better able to use available information and support in a way that reduced uncertainty rather than intensified concern.

In our study, SWB was also identified as a key factor in reducing symptoms of anxiety and depression. SWB refers to an individual's sense of inner peace and harmony, as well as a strong connection to spirituality and religious beliefs. During pregnancy, many women experience heightened levels of anxiety and depression due to significant physical and emotional changes. SWB can serve as a supportive and empowering psychological and emotional resource. Mothers with higher levels of SWB tend to report greater feelings of hope and reassurance, which may help them better cope with the challenges of pregnancy and childbirth.

This finding is consistent with studies such as that of Noormohammadi et al. (2020), which demonstrated that increased SWB is significantly associated with lower rates of postpartum depression. Numerous empirical studies have also supported the beneficial effects of spirituality on mental health. For example, a study conducted in Indonesia found that both religious and existential dimensions of spirituality contributed to reduced anxiety levels and improved overall mental health outcomes (Hamka et al. 2022). Furthermore, systematic reviews have shown that interventions aimed at enhancing SWB effectively reduce symptoms of anxiety and depression across various populations (Aggarwal et al. 2023). In contrast to our findings, a study by Rahimnejad et al. (2020) reported no significant association between SWB and maternal anxiety. This discrepancy may be attributed to differences in demographic characteristics or variations in the assessment tools used.

Another key finding of this study was the significant impact of maternal education level on HL. Specifically, mothers with university‐level education demonstrated higher levels of HL compared to those with only primary or secondary education. This result is expected, as individuals with higher education generally possess greater skills and capacity to seek, comprehend and utilize health‐related information.

Consistent evidence from prior research indicates that individuals with higher educational attainment tend to exhibit better HL. This association is often attributed to the enhanced critical thinking and comprehension skills that are cultivated through advanced education. For instance, one study reported that educational level significantly influences HL, with individuals in higher education brackets showing superior abilities in accessing and interpreting health information (Svendsen et al. 2021). In particular, among pregnant women, those with higher education are more likely to actively engage with health information, which in turn improves health outcomes for both themselves and their families. This pattern highlights the importance of implementing educational interventions aimed at improving health literacy, especially among low‐literacy populations (Health Literacy, n.d.).

The data analysis revealed that SWB increased with advancing age. This finding aligns with previous research indicating that older individuals tend to place greater value on spirituality and non‐material aspects of life. Suggesting that older individuals tend to place greater emphasis on spirituality, meaning and non‐material aspects of life and may rely more on spiritual resources for coping with stress and adversity. In the context of pregnancy, older women may draw on accumulated life experience and more established belief systems, which can enhance their capacity for spiritual coping and emotional regulation (Chehrazi et al. 2021). Nevertheless, age‐related differences in SWB may also be confounded by factors such as parity, prior pregnancy experiences and generational differences in religious practice, and cross‐sectional data cannot fully separate age effects from cohort effects. For example, the study by Rahimnejad et al. (2020) also reported that older adults are more inclined toward spirituality and enhanced SWB, as it can serve as a source of psychological comfort and emotional support (Rahimnejad et al. 2020).

This study holds considerable clinical implications. The findings may be useful in designing educational and healthcare programs aimed at improving HL and SWB among pregnant women. Health policymakers can utilize these results to develop targeted strategies to reduce depression and anxiety in this population. It is recommended that HL and SWB education be integrated into routine prenatal and postpartum care services provided at healthcare centers.

However, several limitations should be considered when interpreting the results. First, the cross‐sectional and associational nature of the study design precludes any causal inferences; therefore, terms such as ‘protective effect’ should be interpreted as statistical associations only. Second, the convenience sampling method and the single‐centre, single‐country setting (Iran) limit the generalizability of the findings to other healthcare systems or cultural contexts. Third, the exclusion of women with lower education (below grade five) and those with severe psychiatric or medical conditions restricts the applicability of the results to the broader population of pregnant women. Fourth, the use of self‐reported questionnaires may introduce response bias, including social desirability bias, potentially affecting the accuracy of the reported symptoms. Fifth, the sample size, while adequate for the regression models, was relatively small for complex subgroup analyses. Expanding the research to multiple centres with more diverse populations could yield more comprehensive and representative results.

5. Conclusion

The findings of our study indicate that both HL and SWB can have a direct impact on maternal mental health during pregnancy and the postpartum period. In particular, higher levels of HL and SWB were associated with reduced symptoms of depression and anxiety.

Author Contributions

M.H.Y. and M.F. designed and conducted the project, S.K. analysed the data, S.S. wrote the primary draft of the paper, and N.T. collected the data. All authors reviewed the paper and approved the final manuscript.

Funding

This work was supported by the Babol University of Medical Sciences (Grant Number: 724134907). The funder reviewed the project plan and awarded a small grant to implementation of the project.

Ethics Statement

The research proposal for this study was approved by the Ethics Committee in Research at Babol University of Medical Sciences, with the code IR.MUBABOL.HRI.REC1403.066. Confidentiality and protection of participants' privacy were ensured, and the obtained information was kept confidential. The research results will be disclosed without mentioning the names or personal details of the individuals involved.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.