Association of maternal conflict with psychological symptoms and maternal role satisfaction in pregnant women: a cross-sectional study in Iran

Abstract

Objectives

This study aimed to examine the relationship between maternal conflict and psychological symptoms (depression and anxiety) as well as maternal role satisfaction among pregnant women. It also explored the associations between demographic characteristics and maternal conflict and role satisfaction.

Design

A cross-sectional design was employed. The study was conducted among pregnant women attending healthcare centres affiliated with Babol University of Medical Sciences, Iran, during 2022–2023.

Setting

Babol, Iran, between March 2022 and February 2023.

Participants

Data were collected from 182 pregnant women attending healthcare centres affiliated with Babol University of Medical Sciences. Women were included if they were pregnant, able to complete self-report questionnaires and provided informed consent to participate. Data were collected using the Maternal Ambivalence Scale, the Brief Symptom Inventory-18 and the Maternal Role Satisfaction Scale. Descriptive statistics, Pearson correlation coefficients and multiple regression analyses were conducted to examine relationships between maternal conflict, psychological symptoms, role satisfaction and demographic factors.

Results

Multivariate linear regression indicated that maternal conflict (B=0.202, p<0.001) and increasing the number of pregnancies (B=2.599, p=0.006) were positively associated with psychological distress, whereas a history of live birth was negatively associated with psychological distress (B=−2.857, p=0.014). Furthermore, maternal conflict had positive associations with maternal role satisfaction (B=−1.229, p<0.001), accounting for 52% of the variance (R² = 0.52). Demographic variables did not associate statistically significant with maternal role satisfaction.

Conclusion

Maternal conflict during pregnancy is associated with increased psychological symptoms and decreased maternal role satisfaction. Screening for maternal conflict in prenatal care and developing interventions to help women manage conflicting feelings about motherhood are essential. Healthcare providers should be aware of the impact of maternal conflict on maternal mental health and mother–infant bonding.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Use of validated measurements ensured reliable assessment of key constructs.

• Convenience sampling from a single clinical setting may limit external validity.

• Cross-sectional design restricts causal interpretation of observed associations.

• Lack of adjustment for some confounders such as social support and prior psychiatric disorder history may influence findings.

• Reliance on self-report measures introduces potential reporting bias.

Introduction

Pregnancy represents a profound developmental transition, marked by complex physiological, psychological and social reorganisation.¹ While traditionally idealised as a period of unequivocal joy, contemporary perinatal research increasingly recognises the nuanced and often contradictory emotional landscape experienced by expectant mothers.² A central, yet frequently underexplored, phenomenon within this landscape is maternal conflict, also termed maternal ambivalence, which refers to the coexistence of positive and negative feelings toward the pregnancy, the fetus and the impending maternal role.³ Emerging evidence indicates that maternal conflict is linked to a spectrum of adverse psychological outcomes, including heightened symptoms of depression and anxiety, and is associated with reduced maternal role satisfaction. These findings underscore the potential implications of maternal ambivalence for both antenatal well-being and postpartum adaptation.^{4 5} Moreover, individual and contextual factors—such as attachment style, pregnancy intention, perceived social support, socio-economic status and cultural norms—play a significant role in shaping the intensity and subjective experience of maternal ambivalence.6,8

The conceptualisation of maternal ambivalence has evolved significantly, moving from a pathologised view in early psychoanalytic thought toward a more normative understanding within modern developmental psychology.⁹ Early theorists often framed any maternal negativity as a deviation from the ideal, whereas contemporary perspectives acknowledge that ambivalence is a common and potentially adaptive part of the psychological work required to integrate the new identity of ‘mother’.¹⁰ This shift recognises that the transition to motherhood involves not only gain but also significant loss—loss of autonomy, professional identity and previously established roles—which naturally generates conflicting emotions.^{11 12}

Empirical evidence indicates that a substantial proportion of pregnant women experience maternal ambivalence, with approximately 16% of women explicitly reporting pregnancy-related ambivalence. These ambivalent feelings tend to intensify around the third trimester and the time of childbirth as the reality of motherhood becomes imminent.^{13 14} These conflicting emotions can manifest in various ways, including joy about the pregnancy coupled with anxiety about the future, love for the unborn baby mixed with resentment toward the constraints of pregnancy or excitement about motherhood alongside grief for one’s former life.¹⁵

The cultural context plays a pivotal role in shaping how maternal conflict is experienced, expressed and managed.¹⁶ These intense societal pressures can create a significant dissonance for women experiencing ambivalence, leading to heightened feelings of guilt, shame and isolation. This cultural stigma can exacerbate psychological distress, as women may feel they are failing to live up to the ideal of the ‘good mother’ and may therefore be reluctant to seek support.¹⁷ In the Iranian cultural context, motherhood is strongly embedded within pronatalist values and traditional gender norms, where women are often expected to embrace pregnancy with positivity and emotional readiness. Such expectations may intensify internal conflict when ambivalent feelings arise, as expressing negative emotions toward pregnancy can be perceived as socially undesirable. Moreover, limited access to formal psychological support and stigma surrounding mental health services in some settings may further shape how maternal conflict is experienced and reported. Therefore, the Iranian context may influence the severity of maternal conflict and its psychological distress and expression patterns.18,20

Despite growing recognition of maternal conflict as a critical perinatal issue, significant gaps in the literature remain. Much of the existing research has focused on the postpartum period, leaving the experience of conflict during pregnancy less understood.^{21 22} Furthermore, the specific relationships between maternal conflict and key outcomes such as psychological symptoms and maternal role satisfaction within the antenatal period require further elucidation, particularly in non-Western cultural contexts.²³ This study aims to address these gaps. This was the first study to investigate the association of maternal conflict with psychological distress and maternal role satisfaction among Iranian pregnant women. Thus, this study had two hypotheses; first, there is an association between maternal conflict and psychological distress in pregnant women. Second, there is an association between maternal conflict and maternal role satisfaction in pregnant women. Understanding these relationships is crucial for informing prenatal care practices, developing effective mental health screening protocols and creating supportive interventions for women navigating this complex life transition.

Methods

Participants and procedure

This cross-sectional study was conducted on pregnant women who were visiting prenatal clinics at healthcare centres affiliated with Babol University of Medical Sciences in Iran between March 2022 and February 2023. Inclusion criteria were: (1) age 18 years or older, (2) education level above fifth grade to ensure comprehension of the questionnaires, (3) pregnancy beyond the first trimester (12 weeks gestation), as ambivalence often solidifies after this point and (4) provision of informed consent. Exclusion criteria included self-report of a current severe psychiatric disorder (eg, psychosis, bipolar disorder) or a known major fetal anomaly, as these could independently affect the variables of interest. A convenience sampling method was used to recruit participants. A total of 195 women were approached, and 182 agreed to participate and completed all study measures, resulting in a response rate of 93.3%. Sample size was determined a priori using G*Power software.²⁴ To detect a medium effect size (f² = 0.15) with 80% power (1-β = 0.80) at an alpha level of 0.05 for a multiple regression with up to six independent variables, a minimum sample of 97 was required. The final sample of 182 was more than sufficient to meet this requirement and to ensure the stability of the correlation analyses.

The data of this study was entered in Babol Pregnancy Mental Health Registry.²⁵ Trained research assistants approached potential participants in the clinic waiting rooms. After explaining the study’s purpose, procedures, risks and benefits, written informed consent was obtained from all participants. Participants then completed the self-report questionnaires independently in a private area of the clinic. Completion took approximately 20–25 min. All data were kept confidential and anonymised to protect participant privacy.

Patient and Public Involement

Patients and/ or the public were not involeved i the desige, or conduct, or reporting, or disswmination plans of this research.

Maternal Ambivalence Scale

This 14-item scale assesses maternal conflict across three dimensions: maternal ambivalence (eg, ‘I have mixed feelings about my pregnancy’), rejection/criticism (eg, ‘I sometimes regret being pregnant’) and coping/suppression (eg, ‘I try not to think about my negative feelings’). Items are rated on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). A total mean score is calculated, with higher scores indicating greater maternal conflict. The scale was translated into Persian using a rigorous forward-backward translation process. The Persian version demonstrated excellent psychometric properties in this study, with a Cronbach’s alpha of 0.86 for the total scale.

Brief Symptom Inventory

This widely used 18-item instrument assesses psychological distress across three dimensions: somatisation (6 items), depression (6 items) and anxiety (6 items). Participants rate how much they have been bothered by each symptom in the past week on a 5-point scale (0=Not at all to 4=extremely). The Global Severity Index provides a measure of overall distress. The Brief Symptom Inventory-18 has been validated in numerous languages and contexts, including Persian, and demonstrates strong reliability.²⁶ In this study, Cronbach’s alpha for the depression and anxiety subscales were 0.89 and 0.87, respectively.

Maternal Role Satisfaction Scale

This 16-item scale measures a pregnant woman’s satisfaction with her impending maternal role across two dimensions: sense of competence (eg, ‘I feel confident I will be a good mother’) and interest/investment (eg, ‘I am excited about the prospect of being a mother’). Items are rated on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate greater maternal role satisfaction. The scale showed strong internal consistency in this study (Cronbach’s α=0.91).

Demographic questionnaire

A brief questionnaire was developed by the researchers to collect information on age, education level, gestational age, number of pregnancies (gravidity) and pregnancy intention (intended vs unintended) (see online supplemental file 1 for the Persian measurements).

Data analysis

Data were analysed using SPSS V.27. Descriptive statistics including means, SD, frequencies and percentages were calculated for demographic and study variables. Pearson correlation coefficients were used to examine the bivariate relationships between maternal conflict, psychological distress and maternal role satisfaction.

To further examine these associations, univariable and multivariable linear regression analyses were performed. In the univariable models, maternal conflict was entered as the sole independent variable for psychological distress and maternal role satisfaction separately. In the multivariable models, maternal conflict together with demographic and reproductive variables including age group, education level, number of pregnancies, history of miscarriage, history of stillbirth and history of live birth were entered simultaneously to control for potential confounding effects.

Regression assumptions including normality of residuals, homoscedasticity, independence of errors and multicollinearity were assessed before conducting the analyses. Unstandardised coefficients (B), standardised coefficients (β), 95% CIs and p values were reported. Statistical significance was considered at p<0.05.

Result

Descriptive statistics and correlations

The demographic characteristics of the 182 participants are presented in table 1. The mean age of the participants was 28.6 years (SD=5.2), with the largest proportion (51.6%) falling within the age range of 26–35 years. Approximately half of the women (52.7%) had a high school education or lower. Regarding reproductive history, 40.1% were experiencing their first pregnancy, whereas 34.6% had two pregnancies and 25.3% reported three or more pregnancies. A history of miscarriage was reported by 24.7% of the participants, and only 2.2% reported a history of stillbirth. Additionally, 47.8% had a previous live birth.

Table 1. Demographic characteristics of participants (N=182).

Variable		Number	Percentage
Age (years)	<25	40	22.0
	25–35	94	51.6
	>35	48	26.4
Education level	≤High school	96	52.7
	>University	86	47.3
Number of pregnancies	1	73	40.1
	2	63	34.6
	≥3	46	25.3
History of miscarriage	Yes	45	24.7
	No	137	75.3
History of stillbirth	Yes	4	2.2
	No	178	97.8
History of live birth	Yes	87	47.8
	No	95	52.2

The results of Pearson correlation analysis indicated there was a significant positive correlation between total score of maternal conflict and psychological distress (r=285 P < 0.001). Also, there was a significant negative correlation between maternal conflict and maternal role of satisfaction (r=−0.75, p<0.001).

Table 2 presents the results of two linear regression models for association between maternal conflict and psychological distress. In the univariate model, maternal conflict was entered as the sole independent variable and explained approximately 9% of the variance in psychological distress (R² = 0.09). Maternal conflict was positively associated with psychological distress (B=0.193, p<0.001), indicating that higher maternal conflict was associated with increased psychological distress. In the multivariate model, demographic variables were added alongside maternal conflict as independent variables, increasing the explained variance to 14% (R² = 0.14). In this model, both maternal ambivalence (B=0.202, p<0.001) and increasing the number of pregnancies (B=2.599, p=0.006) were positively associated with psychological distress, whereas a history of live birth was negatively associated with psychological distress (B=−2.857, p=0.014). However, other demographic factors did not associate with psychological distress statistically significant (p>0.05).

Table 2. Results of linear regression of association between maternal conflicts with psychological distress in pregnant women.

Model	Unstandardised coefficients		Standardised Coefficients Beta (β)	t	P value	95% CIs Lower bound Upper bound
	B	SE
Univariable model
Maternal conflict	0.193	0.048	0.285	3.996	<0.001	0.098	0.289
Multivariable model
Maternal conflict	0.202	0.048	0.299	4.248	<0.001	0.108	0.296
Age groups (years) (>25, 25–25, 35>)	0.566	0.449	0.098	1.259	0.210	−0.321	1.452
Education (High school /university)	0.401	0.581	0.050	0.691	0.490	−0.745	1.548
Number of pregnancy (1,2, 3≥)	2.599	0.933	0.514	2.786	0.006	0.758	4.440
History of abortion No/Yes	−1.614	1.161	−0.173	−1.391	0.166	−3.905	0.676
History of stillbirth No/Yes	0.879	2.113	0.032	0.416	0.678	−3.291	5.049
History of live childbirth No/Yes	−2.857	1.153	−0.355	−2.478	0.014	−5.131	−0.582

Univariable model. Dependent variable: psychological distress. Independent variable: maternal conflict.

Multivariable model. Dependent variable: psychological distress. Independent variables: maternal conflict, age groups (>25, 25–25,<35 years), education (high school/university), number of pregnancy (1, 2, 3≥), history of abortion (no/yes), history of stillbirth (no/yes), history of childbirth (no/yes).

Continuous variables: maternal conflict score and number of pregnancies. Binary variables were coded as 0=No and 1=Yes for history of miscarriage, history of stillbirth and history of live birth. Education was coded as 0=high school or lower and 1=university education. Age group and number of pregnancy were entered as an ordinal categorical variable.

Table 3 shows the results of two linear regression models examining the association between maternal conflict and maternal role satisfaction. In the univariate regression model, maternal conflict alone was entered as the independent variable. Maternal conflict was negatively associated with maternal role satisfaction (B=−1.282, p<0.001), accounting for 52% of the variance (R² = 0.52). In the multivariate regression model, maternal conflict remained significantly associated with maternal role satisfaction (B=−1.229, p<0.001). The addition of demographic variables did not materially alter the association. None of the demographic variables were significantly associated with maternal role satisfaction (p>0.05).

Table 3. Results of linear regression of association between maternal conflicts with maternal role satisfaction in pregnant women.

Model	Unstandardised coefficients		Standardised Coefficients Beta (β)	t	P value	95% CIs Lower bound Upper bound
	B	SE
Univariable model Maternal conflict	−1.282	0.083	−0.756	−15.496	<0.001	−1.445	−1.119
Multivariable model Maternal conflict	−1.229	0.082	−0.725	−14.937	<0.001	−1.392	−1.067
Age groups (years) (>25, 25–25, 35>)	0.486	0.776	0.034	0.627	0.532	−1.045	2.018
Education (High school /university)	−1.293	1.003	−0.064	−1.289	0.199	−3.273	0.687
Number of pregnancy (1,2, 3≥)	0.279	1.611	0.022	0.173	863	−2.901	3.459
History of abortion No/Yes	−0.740	2.005	−0.032	−0.369	0.712	−4.697	3.217
History of stillbirth No/Yes	5.695	3.650	0.083	1.560	0.121	−1.509	12.898
History of live childbirth No/Yes	−3.438	1.991	−0.170	−1.727	0.086	−7.368	0.491

Univariable model. Dependent variable: maternal role satisfaction. Independent variable: maternal conflict.

Multivariable model. Dependent variable: maternal role satisfaction. Independent variables: maternal conflict, age groups (>25, 25–25,<35 years), education (high school/university), number of pregnancy (1, 2, 3≥), history of abortion (no/yes), history of stillbirth (no/yes), history of childbirth (no/yes).

Continuous variables: maternal conflict score and number of pregnancies. Binary variables were coded as 0=No and 1=Yes for history of miscarriage, history of stillbirth and history of live birth. Education was coded as 0=high school or lower and 1=university education. Age group and number of pregnancy were entered as an ordinal categorical variable.

Discussion

This study examined the relationships between maternal conflict, psychological symptoms and maternal role satisfaction among pregnant women. Overall, the findings provide strong support for the study’s hypotheses and align with international literature, while also highlighting dynamics specific to the Iranian cultural context.

Maternal conflict was positively associated with maternal distress in pregnant women. Women experiencing higher levels of conflict reported greater psychological distress, even after controlling for demographic variables. This is consistent with prior research identifying ambivalence as a key risk factor for perinatal mood and anxiety disorders.^{27 28} One plausible explanation is the cognitive dissonance created by holding contradictory feelings about a major life transition, which inherently increases stress.²⁹ In a cultural context such as Iran, where motherhood is idealised, ambivalence may be amplified by guilt and shame—core components of depression.³⁰ Simultaneously, worry, rumination and fear of judgement, which often accompany ambivalence, are hallmark features of anxiety disorders.³¹ It is also possible that this relationship is bidirectional; women with pre-existing vulnerabilities to depression or anxiety may interpret pregnancy challenges negatively, further fuelling ambivalence.³² While the association between maternal conflict and psychological distress is consistent with findings from previous studies, the magnitude and expression of this relationship may be context-specific. In Iran, strong cultural expectations surrounding idealised motherhood may amplify feelings of guilt, potentially intensifying the psychological burden of ambivalence. In contrast, in more individualistic societies where ambivalence may be more openly acknowledged, its psychological impact may be attenuated. Therefore, while the direction of associations appears broadly generalisable, the mechanisms may differ.17,1933

Interestingly, the study found with increasing number of pregnancies the psychological distress increased, while having a history of having a child the psychological distress decreased. Repeated pregnancies, particularly in resource-constrained environments, may increase stress, caregiving burden and role strain, thereby elevating distress levels.^{34 35} In contrast, previous live birth experience may enhance maternal self-efficacy, familiarity with pregnancy-related changes and confidence in maternal abilities, which can serve as protective factors against distress.³⁶ This interpretation is supported by longitudinal studies indicating that maternal competence and prior parenting experience buffer against perinatal distress.^{37 38}

Maternal conflict also statistically significantly undermined maternal role satisfaction. Women with higher ambivalence reported lower confidence and contentment with their impending maternal identity. This supports theoretical models suggesting that successfully integrating the maternal role requires positive emotional investment and acceptance.³⁹ Ambivalence may erode role satisfaction through persistent self-doubt about being a ‘good enough’ mother or difficulty coping with losses associated with the transition to motherhood.⁴⁰ Clinically, this is highly relevant, as low antenatal role satisfaction predicts postpartum adjustment difficulties and impaired mother–infant bonding.⁴¹ Intervening during pregnancy to address maternal conflict could therefore have cascading benefits for both mother and child.

These findings underscore the importance of moving beyond idealised models of pregnancy and motherhood, recognising that conflict can be a normative part of the transition.⁴² Motherhood should be understood as a complex psychological identity that is actively constructed rather than solely instinctual. Clinically, the results advocate for routine screening of maternal conflict during prenatal care. Simple, validated questions about mixed feelings, worries or doubts could be incorporated into standard visits. Creating safe, non-judgmental spaces for women to express ambivalence is crucial, and healthcare providers should be trained to normalise these experiences to reduce stigma.^{43 44}

For women identified with high levels of conflict, targeted interventions—such as cognitive–behavioural therapy, mindfulness-based strategies or group programmes—may provide substantial benefits, fostering coping skills, reducing isolation and promoting shared experiences.^{45 46} In sum, this study highlights the central role of maternal conflict in shaping both psychological well-being and maternal role satisfaction during pregnancy. Addressing ambivalence in clinical practice may not only alleviate distress but also support healthier maternal identity formation, ultimately benefiting both mothers and their infants.

From a practical perspective, these findings highlight the need for integrating mental health screening into routine prenatal care, particularly focusing on maternal conflict. Psychological support programmes may help normalise ambivalence and reduce distress. At the policy level, strengthening access to perinatal mental health services and reducing stigma associated with psychological help-seeking could improve maternal outcomes.

Strengths and limitations

This study demonstrates several strengths, including the use of validated instruments and a sufficiently large sample, enhancing both reliability and statistical power. However, limitations should be acknowledged. First, the cross-sectional design precludes causal inferences, leaving open the possibility that psychological distress influences maternal ambivalence or that both are affected by unmeasured factors.⁴ Compared with longitudinal studies, which demonstrate dynamic changes in maternal emotions across pregnancy and postpartum, the present cross-sectional design captures associations at a single time point. Longitudinal evidence suggests that maternal ambivalence may fluctuate and interact with evolving psychological states over time.^{37 38} Therefore, this study expands prior work by highlighting the role of maternal conflict specifically during pregnancy, but future longitudinal research is needed to establish temporal directionality.

Second, the relatively small sample size and recruitment from a single centre may limit generalisability. Third, potential confounding variables such as perceived social support and prior psychiatric history were not assessed, although they are known to influence both maternal conflict and psychological distress. Finally, the reliance on self-report questionnaires introduces the possibility of reporting bias, particularly in a cultural context where expressing ambivalence may be stigmatised.

These limitations highlight several avenues for future research. Longitudinal studies are needed to track maternal conflict from early pregnancy through postpartum, clarifying causal relationships and key intervention periods.³⁸ Multimethod approaches, including observational data or partner reports, could reduce reliance on self-report. Cross-cultural studies are essential to examine how societal norms and support structures influence maternal conflict.²⁰ Finally, intervention research is needed to test programmes designed to help women manage ambivalent feelings and improve perinatal mental health outcomes.

Conclusion

This study provides compelling evidence that maternal conflict during pregnancy is associated statistically significant with increased psychological distress and decreased maternal role satisfaction. Maternal ambivalence is therefore not merely a benign emotional state, but a critical factor affecting the mental well-being of expectant mothers. These findings underscore the importance of prenatal care systems in recognising, validating and addressing maternal conflict. By screening for ambivalence and creating supportive environments where women can express the full range of their emotions, healthcare providers can promote healthier psychological adaptations to pregnancy and motherhood, ultimately benefiting both mother and child. Future research should further examine interventions aimed at addressing maternal ambivalence and supporting psychological well-being throughout pregnancy and the postpartum period.

Data availability statement

Data are available upon reasonable request.