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The multiple mediation model of social support and postpartum anxiety symptomatology: the role of resilience, postpartum stress, and sleep problems

BMC Psychiatry volume 24, Article number: 630 (2024) Cite this article

Abstract

Objective

This study aimed to assess the prevalence of postpartum anxiety and the factors influencing it, while also exploring the multiple mediating roles of related factors between social support and postpartum anxiety symptomatology among postpartum women in China.

Methods

Between April and August 2023, we recruited a total of 824 postpartum women through a convenience sampling method. These participants completed a series of general survey questionnaires and were evaluated using the depression anxiety stress scale, perceived social support scale, 10-item Connor–Davidson resilience scale, maternal postpartum stress scale, and Pittsburgh sleep quality index. Additionally, we employed a hierarchical multiple regression model to investigate the relevant factors and mediators of postpartum anxiety symptomatology. A structural equation model was used to examine the mediating role of resilience, postpartum stress, and sleep problems in the relationship between social support and postpartum anxiety symptomatology.

Results

Our study found a postpartum anxiety symptomatology prevalence rate of 18.40%. The factors influencing postpartum anxiety symptomatology included age, education of their husband, mastitis, social support, resilience, postpartum stress, and sleep problems. Through a multiple mediation analysis, we found that resilience, postpartum stress, and sleep problems completely mediated the effects of social support on postpartum anxiety symptomatology, with the mediating effect accounting for 83.57% of the total effect.

Conclusion

The multiple mediation analysis revealed that among postpartum women, the impact of social support on postpartum anxiety symptomatology is channeled through resilience, postpartum stress, and sleep problems. Therefore, enhancing social support, resilience, postpartum stress, and sleep problems might alleviate postpartum anxiety symptomatology.

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Introduction

Postpartum anxiety refers to a psychological disorder characterized by anxiety that develops after childbirth. This condition is typically accompanied by intrusive thoughts, palpitations, difficulty falling asleep, worry, and other symptoms related to neurological dysfunction [1]. Postpartum anxiety can have severe implications for women and their infants, such as an elevated likelihood of obstetric complications, disruptions in maternal-infant attachment, challenging infant temperament, and delayed cognitive development in infants [1]. A previous meta-analysis has indicated that the estimated global prevalence of postpartum anxiety disorders is as high as 15.2% [2]. Additionally, a recent meta-analysis conducted in mainland China revealed a higher prevalence rate of 17.5% [3]. Considering the detrimental effects of postpartum anxiety on health, as well as the significant number of postpartum women in China, it is crucial to enhance the identification of potential risk factors and protective factors in order to reduce the incidence of postpartum anxiety.

During the postpartum period, several factors have been recognized as predictive risk factors for postpartum anxiety symptomatology, including low resilience [4], elevated postpartum stress [5], poor sleep problems [6], and insufficient perceived social support [7]. Perceived social support is strongly associated with the development of postpartum anxiety symptomatology, with higher levels offering significant preventive and protective benefits, indicating a moderate to strong effect size [8]. Perceived social support reflects the extent to which individuals feel understood, supported, and respected by friends, family members, or significant others in their social environment [9]. Within the framework of motherhood, diminished levels of perceived social support amplify the susceptibility to postpartum anxiety symptomatology, whereas enhanced levels serve as a protective barrier against it. Besides, even including aspects such as depression, socioeconomic position, and marital status in the consideration, Chavis [8] identified that the perception of social support significantly contributes to the variance in the levels of anxiety of women. Therefore, robust social support can effectively alleviate postpartum anxiety symptomatology in women.

Postpartum stress during the postpartum period has been associated with elevated levels of postpartum anxiety symptomatology, reflecting a moderate effect size [10]. Predictors of sustained anxiety in the postpartum period include perceived stress and social support [5, 11]. Increased social support has been correlated with reduced levels of perceived stress and greater resilience against negative mental health outcomes [12, 13]. While one study indicated that both social support and postpartum stress independently impact postpartum anxiety symptomatology, it did not support social support as a mediator of the relationship between postpartum stress and postpartum anxiety symptomatology [14]. As a result, our research aims to investigate whether postpartum stress serves as a mediator between social support and postpartum anxiety symptomatology.

New mothers often find themselves susceptible to the adverse effects of sleep disruptions during the postpartum period [15]. Inadequate sleep is closely associated with greater psychological distress and increased vulnerability to mood disorders such as anxiety and depression [16]. Research has shown that improved sleep quality, when combined with strong social support, exhibits a moderate positive association with mental health in this demographic, suggesting that better sleep may contribute to weaker anxiety symptomatology [17]. During the postpartum period, mothers increasingly rely on fathers for social support, and enhanced social support can lead to improved sleep quality and a reduction in the occurrence of postpartum anxiety symptomatology [18]. Consequently, our research also explores whether sleep problems serves as a mediator in the relationship between social support and postpartum anxiety symptomatology.

Resilience, now understood as a dynamic capacity, is central to the adaptation to postpartum adversities. It involves a complex interplay of factors that enable individuals to navigate and adapt to stressors, such as postpartum challenges, in a fluid and evolving manner [19]. This concept aligns with the current thinking on resilience as outlined by Rutter [20] and further elaborated by Kalisch et al. [21], which emphasizes the role of dynamic systems in psychological adjustment. Resilience, as a dynamic system, significantly influences the mitigation of anxiety, particularly through its impact on sleep quality. High levels of resilience, characterized by a person’s ability to adapt and respond to stress in a healthy way, are associated with reduced anxiety symptomatology, reflecting a strong inverse relationship [22]. This dynamic relationship is crucial in understanding how resilience operates within the context of postpartum mental health. Prior studies have consistently demonstrated lower levels of stress in individuals with high resilience [23, 24], suggesting that individuals with resilience exhibit greater resistance to stressors. It is worth noting that resilience may have an inverse relationship with the perception of stress and anxiety [25]. Furthermore, research underscores the dynamic relationship between social support and resilience, suggesting that increased social support is linked to enhanced resilience. This dynamic interplay is essential in reducing the risk of stress-related outcomes, particularly in the postpartum period, and can facilitate early identification of those at risk of experiencing adverse psychological consequences [26]. In summary, the dynamic construct of resilience is interwoven with social support, postpartum stress, and sleep problems, highlighting the complex and adaptive nature of these factors in influencing postpartum anxiety symptomatology. This perspective aligns with contemporary views that emphasize the fluidity and changeability of resilience in response to social support and stress. Resilience, in turn, may influence anxiety by mediating the effects of sleep problems and stress.

A review of the previous literature has highlighted the critical roles that perceived social support, resilience, postpartum stress, and sleep problems play in the context of postpartum anxiety symptomatology. However, past research has primarily examined the influence of these factors on postpartum anxiety symptomatology individuals, with limited attention given to exploring the interconnectedness among these factors. Furthermore, the potential influence of these mechanisms on anxiety disorders among women remains unclear. Therefore, based on the above literature analysis and theories, we hypothesized that resilience, postpartum stress, and sleep problems serve as the multiple mediators for the association between social support and postpartum anxiety symptomatology (Fig. 1, Hypothetical Model).

Fig. 1
figure 1

Hypothetical model of this study

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In this study, we aimed to (1) to explore the prevalence rate of postpartum anxiety symptomatology and the factors influencing it; and (2) to examine whether and to what extend resilience, postpartum stress, and sleep problems mediate the relationship between social support and postpartum anxiety symptomatology. The findings of this study have the potential to enhance our understanding of the mechanisms contributing to postpartum anxiety symptomatology, ultimately aiding in the development of effective prevention and intervention strategies for the future.

Materials and methods

Participants

Research participants in this study were selected using the convenience sampling method. Postpartum women who had undergone a physical examination 42 days after delivery at three hospitals in Nantong, China, were chosen between April and August 2023. The postpartum women who had undergone a physical examination 42 days after delivery’ were part of a routine postpartum care regimen, which is in line with the WHO guidelines that recommend such an examination as a standard component of maternal care. This examination is scheduled around 6 weeks postpartum and is crucial for assessing the mother’s recovery from childbirth and addressing any emerging postpartum issues. It is not solely optional but is often encouraged or required as part of standard postpartum care to ensure the mother’s physical and mental well-being. The examination includes assessments of vital signs, wound healing, uterine involution, and emotional well-being, with a specific focus on screening for Postpartum psychological. It is important to note that this study was not preregistered. Therefore, the findings and interpretations presented herein should be considered in an exploratory context, highlighting the need for future research to confirm these preliminary results.

The inclusion criteria for this were as follows: (a) maternal age of ≥ 18 years; (b) absence of newborn malformations or serious complications; (c) a willingness to cooperate with the survey, the capability to effectively communicate, and the ability to understand the contents of the questionnaire and complete it independently; and (d) a voluntary commitment to participate. The exclusion criteria were as follows: (a) mental disorders, ascertained via clinical evaluation and medical record scrutiny; (b) mothers with comorbidities, including malignant tumors; and (c) a documented history of mental illness or cognitive dysfunction.

Sample size estimation for this study was done using PASS 21.0 software. The multiple linear regression unconditional effect size estimation method was used, with power (1-β) set at 0.9, significance level (α) set at 0.05, effect size (Cohen’s f²) set at 0.15 (0.02 for low effect, 0.15 for medium effect, 0.35 for high effect), and the dependent variable was the postpartum anxiety symptomatology score. The number of independent variables was set to 27 (23 items from a general data survey as control variables, and perceived social support, sleep quality, psychological resilience, postpartum stress scores as the primary independent variables), and the required sample size was 135 cases. Considering a loss rate of 20%, the actual sample size should be at least 169.

Data collection

The primary data were collected through face-to-face assisted self-report questionnaires in a controlled and quiet environment within the postpartum outpatient clinics of hospitals. This method involved the direct interaction of our research team with the participants to ensure a higher response rate and to aid participants in understanding the questionnaire items more effectively. All professional figures involved in the study include 2 clinical psychologists or psychiatrists, 2 obstetrician-gynecologists, 2 professional nursing staff in obstetrics and gynecology, and 2 graduate students majoring in obstetrics and gynecology. In our research, the psychological assessments were conducted by a team of experienced and licensed psychologists and psychiatrists. These mental health professionals have extensive training in the administration of psychological tests and are well-versed in the diagnosis of various mental health conditions. The research team was trained to maintain a neutral demeanor and to avoid influencing the participants’ responses in any way. Investigators used consent instructions to patiently answer questions participants might have, but did not interfere with their willingness to choose. We emphasized that participation was entirely voluntary, and the participants had the right to withdraw from the study at any point without any consequences. Informed consent was obtained from all participants prior to the commencement of the study. The consent form outlined the study’s details, including its objectives, data collection procedures, potential risks and benefits, measures to ensure confidentiality, and contact information for any inquiries or concerns. Participants were informed that the purpose of the survey questionnaire was to collect information about their postpartum experiences, and that their responses would remain anonymous and confidential. The survey itself lasted approximately 10 to 20 min. The data analysis approaches were designed to explore the relationships between variables, in line with the exploratory nature of this non-preregistered study. This study obtained ethical approval from the Research Ethics Committee of the Affiliated Hospital of Nantong University (approval number: 2022-K150-01).

Measurement

Sociodemographic characteristics

Our research team developed a questionnaire to collect information on the general characteristics of postpartum women. The primary variables included: (1) fundamental demographic details, such as age, body mass index (BMI), place of residence, the educational level of the postpartum women and their husbands, and the monthly income of the family; and (2) factors related to maternity, including a history of abortion, parity, pregnancy-related complications, gestational week of delivery, delivery mode, assisted reproduction, pregnancy weight gain, baby birth weight, feeding patterns, and mastitis.

Depression anxiety stress scale

The depression anxiety stress scale-21 (DASS-21) is used to assess the negative mood of an individual and the severity of symptoms experienced in the previous week [27]. This scale comprises three subscales: anxiety, depression, and stress, each containing seven items, totaling 21 items. A grading system with four levels, ranging from 0 to 3, is utilized, encompassing “completely inconsistent,” “partially consistent,” “mostly consistent,” and “completely consistent.” Higher scores on the scale signify more intense negative emotions. Each subscale is further divided into asymptomatic, mild, moderate, severe, and extremely severe based on the score. For this study, only the anxiety dimension of the DASS-21 was utilized, with a cutoff value of seven points to assess the presence of anxiety. The Cronbach’s alpha coefficient for the anxiety dimension was determined to be 0.82 [28].

Perceived social support scale

The perceived social support scale (PSSS) was used to measure the level of social support [9]. The PSSS comprises 12 items designed to assess support from various sources, including family, friends, relatives, and colleagues. Respondents rate each item on a 7-point Likert scale, ranging from 1 (strong disagreement) to 7 (strong agreement). The total score on this scale ranges from 12 to 84, where higher scores signify a greater perceived level of social support. Specifically, a score falling within the range of 12 to 36 indicates low support, 37 to 60 indicates medium support, and 61 to 84 indicates high support. The Cronbach’s alpha coefficient for PSSS in the current study was 0.914 [29].

Maternal postpartum stress scale

The Maternal postpartum stress scale (MPSS) [30] is a reliable and valid instrument designed to measure self-reported postpartum stress among postpartum women. This scale consists of 22 items, which are categorized into three subscales that assess different aspects of postpartum stress: personal needs and fatigue (nine items), infant nurturing (seven items), and body changes and sexuality (six items). Each item on the scale is rated using a 5-point Likert scoring system, ranging from 0 (not at all) to 4 (completely). A higher total score on the MPSS indicates a higher level of postpartum stress. In the Chinese version of the MPSS, validated by the researchers, the Cronbach’s alpha coefficient for internal consistency was found to be 0.940 [31].

A 10-item Connor–Davidson resilience scale

The Connor–Davidson resilience scale (CD-RISC-10), a 10-item scale co-developed by Connor and Davidson [32], was used in this study. The scale has demonstrated good reliability and construct validity, with a Cronbach alpha coefficient of 0.85. In this study, the Chinese version of CD-RISC-10, which had been translated and revised by Chinese researchers, was used. This translated version exhibited strong psychometric properties, including robust internal consistency, consequential validity, and criterion-related validity, with a Cronbach’s alpha coefficient of 0.92 [33]. This scale was also administered to pregnant women in China [34]. Participants in the study provided responses for each of the 10 items on a 5-point Likert scale, with scores ranging from 0 to 4, corresponding to the responses: “never,” “seldom,” “sometimes,” “frequently,” and “always,” respectively. The CD-RISC-10 score was calculated as the sum of the scores for all items, with higher scores indicating greater resilience.

Pittsburgh sleep quality index

The Pittsburgh sleep quality index (PSQI) [35] is a self-report questionnaire comprising 19 items that examines seven dimensions related to sleep quality. The psychometric properties of the PSQI have been evaluated in the Chinese population [36]. The Chinese version of the PSQI has demonstrated adequate reliability, with Cronbach’s alpha coefficient ranging from 0.77 to 0.84 [37]. The total score on the PSQI ranges from 0 to 21, where higher scores are indicative of poorer sleep quality. Poor sleep quality has been defined as a total score of ≥ 5 by previous studies [38].

Statistical analyses

The general characteristics were presented through descriptive analyses, which included measures such as mean, standard deviation [SD], frequency, and proportion. Data normalization was performed using the Inverse Normal Transformation (INT) to stabilize the variance and meet the assumptions of normality for parametric statistical tests. INT involves applying the inverse of the standard normal cumulative distribution function to the ranked data, which aids in reducing skewness and kurtosis in the dataset. Following this transformation, the postpartum anxiety symptomatology scores adhered to a normal distribution. Student’s t-tests and one-way analysis of 95%variance were used to assess the differences in postpartum anxiety symptomatology scores (after INT) concerning demographic characteristics within the groups. Postpartum anxiety symptomatology scores were assessed using the INT process. Correlation analysis was conducted to examine the association between various scales and the level of postpartum anxiety symptoms, exploring the linear relationships among different factors. Additionally, a stepwise forward approach was employed to construct a multiple linear regression model. To examine mediating effects, the bootstrap method with 5000 iterations was employed, yielding 95% confidence intervals (CIs) for our results. Statistical analyses were performed using IBM SPSS Statistics for Windows (version 25.0; IBM Corp., Armonk, NY) and SPSS PROCESS macro version 4.1. All figures were generated using R version 3.6.2. A type I error level of P < 0.05 (two-sided) was set for all statistical analyses.

Results

Characteristics of the study population

A total of 836 postpartum women were surveyed during the study period. However, two participants dropped out, eight had incomplete data, and two provided invalid answers. Consequently, the final analysis included 824 participants, resulting in a response rate of 98.56%. The data regarding general characteristics included variables such as age, educational level of the postpartum women and their husbands, place of residence, monthly income of the family, parity, pregnancy-related complications, assisted reproduction, feeding patterns, and primary caregivers of the baby (Table 1). Statistical analysis revealed that the postpartum anxiety symptomatology score was not statistically significant in relation to the demographic characteristics of all groups (P > 0.05), except for age (P < 0.001), education of the husband (P = 0.044), and postpartum mastitis (P = 0.008).

Table 1 Characteristics of the subjects enrolled in this study
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Multiple linear regression of postpartum anxiety symptomatology

Multivariate linear regression analysis revealed that higher resilience (β: -0.109, 95% CI: -0.150 to -0.068, P < 0.001), lower postpartum stress (β: 0.111, 95% CI 0.087 to 0.136, P < 0.001), improved sleep quality (β: 0.272, 95% CI 0.181 to 0.362, P < 0.001), and older age of the postpartum women (β: -0.861, 95% CI -1.333 to -0.388, P < 0.001) were independent factors significantly associated with decreased levels of postpartum anxiety symptomatology in postpartum women (Table 2).

Table 2 Multiple linear regression analysis of influencing factors for psychotic prodromal symptoms (R2 = 0.302)
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Correlation analysis

As shown in Table 3, the mean postpartum anxiety symptomatology score was 3.99 ± 4.12. The prevalence of postpartum anxiety symptomatology in our study was 18.4% (95%CI: 15.8-21.1%). We observed a significant and negative correlation between postpartum anxiety symptomatology and social support (r = -0.357, P < 0.001), as well as resilience (r =-0.406, P < 0.001). Conversely, we noted a significant and positive correlation between postpartum anxiety symptomatology and postpartum stress (r = 0.468, P < 0.001), as well as sleep problems (r = 0.374, P < 0.001).

Table 3 Mean, standard deviation (SD), and correlations for study variables (N = 824)
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Mediation analysis

The correlation analysis revealed a significant association between social support and postpartum anxiety symptomatology, indicating that greater social support was associated with lower levels of postpartum anxiety symptomatology. However, when we integrated mediators into the model, the direct effect of social support on postpartum anxiety symptomatology was fully mediated. This resulted in a coefficient of -0.023 (95% CI: -0.053 to -0.007, P > 0.05), accounting for only 16.43% of the total effect.

Subsequently, we identified a multiple mediation model involving resilience, postpartum stress, and sleep problems in the association between social support and postpartum anxiety symptomatology (Fig. 2). The total mediation effect, contributing to the total effect, was − 0.117 (95% CI: -0.144 to -0.092), accounting for 83.57% of the total effect. The five mediating effects of social support on postpartum anxiety symptomatology were as follows: (1) Social support → resilience → postpartum anxiety symptomatology was − 0.038 (95% CI: -0.058 to -0.019), accounting for 27.14% of the total effect; (2) social support → postpartum stress → postpartum anxiety symptomatology was − 0.033 (95%: CI -0.047 to -0.021), accounting for 23.57% of the total effect; (3) social support → sleep problems → postpartum anxiety symptomatology was − 0.010 (95% CI: -0.018 to -0.004), accounting for 7.14% of the total effect; (4) social support → resilience → postpartum stress → postpartum anxiety symptomatology was − 0.022 (95% CI: -0.032 to -0.014), accounting for 15.72% of the total effect; and (5) social support → resilience → sleep problems → postpartum anxiety symptomatology was − 0.014 (95% CI: -0.021 to -0.008), accounting for 10.00% of the total effect (Table 4).

Fig. 2
figure 2

The multiple mediation model of social support and postpartum anxiety symptomatology. *** P < 0.001, * P < 0.05

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Table 4 The multiple mediating effect of resilience, postpartum stress and sleep problems on the relationship between social support and postpartum anxiety symptomatology (incompletely standardized indirect effect(s) of X on Y)
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Discussion

This study revealed that the prevalence rate of postpartum anxiety symptomatology was 18.4%. Maternal age, the presence or absence of mastitis, the educational level of the husband, social support, resilience, postpartum stress, and sleep problems were found to be associated with postpartum anxiety symptomatology. Furthermore, the results of a multiple mediation analysis indicated that resilience, postpartum stress, and sleep problems play a fully mediating role in the relationship between social support and postpartum anxiety symptomatology.

In our study, the prevalence rate of postpartum anxiety symptomatology was found to be 18.4%. However, in a meta-analysis that encompassed over 100 studies from > 30 different countries, the reported prevalence rate of postpartum anxiety symptomatology was approximately 18% within one to four weeks postpartum and around 15% at 5–12 weeks postpartum [2], which is slightly lower than the rate observed in our study (18.4%). This variation might be attributed to a significant portion of the population in China being affected by coronavirus disease 2019 (COVID-19) during pregnancy, experiencing fever symptoms and virus infection during pregnancy, and having concerns about both their own health and the health of their babies. Mothers perceive a substantial impact of COVID-19 on their families and themselves, which could be contributing to the heightened severity of postpartum anxiety symptomatology symptoms [39].

In this study, maternal age, the presence or absence of mastitis, and the educational level of the husband were found to be associated with postpartum anxiety symptomatology. The data suggests that becoming a mother at a younger age is associated with an increased risk of experiencing postpartum anxiety symptomatology. This could be due to the limited resources available to younger mothers, which may be more strongly associated with postpartum anxiety symptomatology. In contrast, older mothers might possess greater social and economic resources that can act as a buffer, protecting their mental health. Younger mothers are more likely to be primipara, lacking experience with pregnancy and delivery, potentially not utilizing family planning services adequately, or facing difficulties in accessing these services. Education level is a commonly used indicator of socioeconomic status [40], and lower socioeconomic status is associated with an increased risk of psychiatric conditions, including anxiety disorders [41]. Husbands with low education levels may struggle to provide adequate postpartum information and financial support to their wives, potentially contributing to a heightened risk of maternal anxiety. While mastitis can develop at any point during the lactation period, it tends to occur more frequently in the initial six to eight weeks following childbirth [42]. The pain experienced by mothers and the breastfeeding challenges they encounter, often prompting early discontinuation, have been associated with higher scores on psychometric assessments aimed at detecting mental health disorders. This, in turn, leads to a decline in the mental well-being of women in the perinatal period [43].

The findings of this study indicate that perceived social support has a negative impact on postpartum anxiety symptomatology, aligning with previous research findings that have consistently identified a low level of perceived social support as a risk factor for postpartum anxiety symptomatology [3, 8]. Social support includes the assistance of family, friends, colleagues, and others who can offer psychological, physical, and financial help when needed [7]. Social support plays a pivotal role in establishing and maintaining one’s self-worth and emotional well-being. Studies have recognized that enhancing the social support of a mother can reduce postpartum anxiety symptomatology among new mothers. Among first-time mothers, the combined effect of perceived social support and maternal sense of competence was linked to a 34% decrease in anxiety levels [8]. Supportive relationships have the potential to enhance feelings of well-being, personal control, and positive affect, as people tend to be happiest and most effective when they have someone to confide in. Family and friends provide a kind of support that extends beyond the daily household tasks typically provided by a significant other, making their support particularly valuable to the mother.

The multiple mediation analysis has revealed that among postpartum women in China, the impact of social support on postpartum anxiety symptomatology is channeled through resilience, postpartum stress, and sleep problems. When facing challenges, postpartum women often view those around them as potential sources of assistance [44]. This positive cognitive model of interpersonal relationships can enhance maternal coping abilities with stressful events, subsequently alleviating negative emotions such as anxiety. Social support, particularly from family and husbands, not only aids mothers in childrearing but also improves the quality of their nighttime sleep and increases their daytime rest. During the night, mothers frequently awaken due to breastfeeding or the baby’s crying, which can disrupt the quality of their sleep. Chronic sleep deprivation and the subjective experience of poor sleep quality are recognized as unique risk factors for postpartum anxiety symptomatology [6, 45]. On the other hand, social support may have a protective effect on sleep outcomes during the perinatal period [46].

Postpartum social support has the potential to enhance maternal mental resilience and alleviate postpartum anxiety symptomatology [47]. sleep problems plays a pivotal role in nurturing resilience, and the improvement of resilience can lead to an enhancement in sleep quality. Abiding by recommended sleep practices has been recognized as a protective coping strategy for dealing with postpartum anxiety symptomatology [48]. Furthermore, it has been proposed that social support, including guidance from pediatricians, can foster resilience strategies to assist new mothers in adapting during the COVID-19 pandemic, ultimately reducing the symptoms of anxiety [48]. Previous longitudinal studies have demonstrated that individuals with higher resilience can mitigate the impact of newly occurring stressors, supporting the buffering hypothesis, which suggests that resilience moderates the influence of stressors on mental health [49]. The support from close family and friends, comprising care, love, and attention, may serve as a potential mechanism through which perceived social support influences mental health by contributing to the preservation of an individual’s sense of self-worth and bolstering their resilience. This, in turn, aids the individual in positively adapting to stress and reducing their psychological distress [50].

In terms of prevalence, we found that the 18.4% rate of postpartum anxiety symptomatology in the sample was slightly higher than the global average for postpartum depression, which was 14% depending on region and time of assessment [51]. This discrepancy suggests that anxiety may be a more prevalent issue immediately following childbirth than previously recognized. When examining risk factors, our study identified unique predictors. However, commonalities such as low social support and sleep problems were noted [6, 52], highlighting the interplay between these conditions. The impact on maternal and infant health is profound for both conditions, with potential consequences for bonding, infant development, and long-term maternal mental health. However, the specific pathways through which anxiety and depression exert these effects may differ. Regarding intervention strategies, while some approaches like cognitive-behavioral therapy are beneficial for both conditions, the emphasis on resilience-building and stress management appears particularly crucial for alleviating anxiety symptoms. In conclusion, by setting our results within the context of postpartum depression research, we can appreciate the nuanced differences and similarities between these two conditions. This understanding is vital for developing a comprehensive approach to maternal mental health support, ensuring that interventions are tailored to address the specific needs of each condition.

This study has several limitations. First, while multiple mediation analysis extends the conventional mediation approach by examining multiple mediators within a single model to estimate the direct and indirect effects of variables simultaneously, it is important to note that this technique may not comprehensively address the complexity of the relationships. Therefore, further research using alternative analyses to investigate and validate this complexity is warranted. Second, it is essential to acknowledge that various factors influence postpartum anxiety symptomatology, and we cannot exclude the possibility that some of these factors may also serve as mediators in the relationship between social support and postpartum anxiety symptomatology. Third, the convenience sampling method, while advantageous for producing expedited results and distributing surveys efficiently, introduces the potential for selection bias, thereby limiting the generalizability of the findings. Fourth, this study adopted a cross-sectional design and was carried out exclusively in three hospitals in China, which restricts the generalizability of the results among postpartum women in other populations. Fifth, in this study, we focused solely on postpartum anxiety symptomatology. However, acknowledging the close relationship and occasional overlap between depressive and anxiety symptoms during the perinatal/postpartum period, we recommend that future research should assess both depressive and anxiety symptoms simultaneously. Sixth, a key limitation of this study is the reliance on self-reported data, which may be subject to biases inherent in self-reporting. This reliance on self-reports could potentially affect the accuracy of the participants’ responses and the generalizability of our findings to other populations or settings where clinical assessments may be used. Seventhly, there is a lack of detailed information regarding participants’ mental health history prior to childbirth. Specifically, our data does not include a comprehensive assessment of pre-existing mental distress and mental disorders, which could potentially contribute to the anxiety reported by some women postpartum.

Conclusion

In our study, the prevalence rate of postpartum anxiety symptomatology was 18.4%. Notably, resilience, postpartum stress, and sleep problems were found to act as complete mediators in the relationship between social support and postpartum anxiety symptomatology. Consequently, enhancing postpartum social support, resilience, and sleep problems among postpartum women while simultaneously reducing postpartum stress can serve as effective measures for the prevention and alleviation of postpartum anxiety symptomatology.

Data availability

Data are available upon reasonable request from the corresponding author.

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Acknowledgements

This study would not have been possible without the generosity of the mothers who spent hours responding to questionnaires. We are very thankful to the mothers for their collaboration to achieve this study.

Funding

This work was supported by Social Science Foundation of Jiangsu Province (22SHB014). The scientific research projects of Nantong Commission of Health (QN2023043). The funding sources had no role to play in the study design, the collection and interpretation of the data, writing of the report, or decision to submit this paper for publication.

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Author notes

  1. Yanchi Wang and Jian Gu contributed equally to this work.

Authors and Affiliations

  1. Affiliated Nantong Hospital of Shanghai University (The Sixth People’s Hospital of Nantong), Nantong, Jiangsu, China

    Yanchi Wang

  2. School of Nursing and Rehabilitation, Nantong University, Nantong, 226001, Jiangsu, China

    Yanchi Wang & Feng Zhang

  3. Department of Nursing, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu, China

    Yanchi Wang & Xujuan Xu

  4. Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, Jiangsu, China

    Jian Gu

Authors
  1. Yanchi Wang
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  2. Jian Gu
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  3. Feng Zhang
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  4. Xujuan Xu
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Contributions

Feng Zhang and Xujuan Xu conceptualized the study. Jian Gu did the analyses and prepared all the tables and figures. Yanchi Wang wrote the first manuscript draft and Feng Zhang offered further guidance on the analyses, interpretation and writing. All authors reviewed the manuscript and approved the manuscript before submission. Xujuan Xu takes full responsibility for the work and/or the conduct of the study, has access to the data, and controlled the decision to publish.

Corresponding authors

Correspondence to Feng Zhang or Xujuan Xu.

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Ethics approval and consent to participate

The study was reviewed and approved by the Ethics Committee of Affiliated Hospital of Nantong University (approval number: 2022-K150-01).

Competing interests

The authors declare no competing interests.

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Wang, Y., Gu, J., Zhang, F. et al. The multiple mediation model of social support and postpartum anxiety symptomatology: the role of resilience, postpartum stress, and sleep problems. BMC Psychiatry 24, 630 (2024). https://doi.org/10.1186/s12888-024-06087-2

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Keywords

BMC Psychiatry

ISSN: 1471-244X

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