Introduction
Pregnant women tend to experience physical discomfort, including decreased mobility, due to the sharp increase in estrogen and progesterone and rapid weight gain. In addition to physical changes, they also experience developmental difficulties as they adjust psychologically to changes in the family structure and psychological difficulties due to ambivalence [
1]. Since the coronavirus disease 2019 (COVID-19) pandemic, pregnant women tend to experience more anxiety and depression than other demographic groups due to deteriorated mental health resulting from social isolation and quarantine measures [
2]. Therefore, they are a vulnerable population with a high risk of deteriorating mental health in the wake of the COVID-19 pandemic [
3].
Pregnant women are at risk of a lower health-related quality of life due to potential physical and mental health problems that occur during pregnancy [
4]. Health-related quality of life (HRQoL) can be conceptualized as an individual’s level of functioning and subjective perception of their overall well-being across multiple dimensions of health, including physical, mental, and social domains [
5]. A meta-analysis of the HRQoL of pregnant women identified demographic factors such as age and gestational age, social factors such as family and friends, physical factors such as nausea and pain, and psychological factors such as anxiety and depression to be the factors that most affect HRQoL [
4]. Another study showed that higher HRQoL was associated with the third trimester of pregnancy compared to the second trimester, maternal age of 26 to 30 years compared to other ages, and not having a job compared to having a job [
6]. In a systematic review by Boutib et al. [
7], the physical factors that affected the HRQoL of pregnant women included nausea, back pain, and pelvic pain; the demographic factors included advanced gestational age and multiple previous deliveries, and the psychological factors included anxiety, and depression. The factors that positively affected HRQoL were social support, physical exercise, and good sleep [
7]. However, the influential factors are not consistent across countries, and few studies have simultaneously examined the physical, mental, and social factors related to pregnant women in Korea. Additionally, there is a lack of research on the HRQoL of pregnant women in the post-pandemic era.
Therefore, this study aimed to examine the effects of perceived physical health status and psychological factors such as anxiety and depression on the HRQoL of pregnant women. Spilker’s [
8] Quality of life (QoL) model was applied as the theoretical framework in this study. The QoL domains were organized in a pyramid model. At the bottom of the pyramid were the elements of each domain; in the middle were the broader domains of mental health, social health, and physical health; and at the top was overall well-being. In this study, we applied a conceptual framework using anxiety and depression to assess mental health, social support to assess social health, and physical health status to assess physical health as the factors that affect pregnant women’s HRQoL (
Figure 1). This study aimed to identify the effects of psychological health, social support, and physical health status on the HRQoL of pregnant women. The determinants of HRQoL in pregnant women identified in this study will serve as a basis for the development of nursing interventions to improve their HRQoL in the domains of mental, social, and physical health.
This study aimed to explore the impact of anxiety, depression, social support, and physical health status on the quality of life of pregnant women in the post-pandemic era. The study’s specific objectives were as follows: (1) to measure the anxiety, depression, social support, physical health status, and HRQoL of pregnant women; (2) to analyze the relationships among anxiety, depression, social support, physical health status, and HRQoL in pregnant women; and (3) to identify the effects of anxiety, depression, social support, and physical health status on the HRQoL of pregnant women.
Discussion
This study found physical health status and social support to be the main factors affecting the HRQoL of pregnant women. This study adopted Spilker’s [
8] quality of life model as its theoretical framework. This framework was partially supported since, among the mental, social, and physical domains, the social domain, which was measured in terms of social support, and the physical domain, which was measured in terms of physical health status, affected the HRQoL of pregnant women. This discussion, therefore, focused on the effects of physical health status and social support on HRQoL. Pregnancy is a normal part of life, but it is also a time during which women’s health is particularly vulnerable, and it involves major physical, mental, and social changes. This study is significant since it holistically identified the factors that most affect the HRQoL of pregnant women based on physical, mental, and social domains, mitigating the existing lack of research on the quality of life of pregnant women following the COVID-19 pandemic.
In this study, physical health status was the most significant factor affecting the HRQoL of pregnant women. Lau and Yin [
21] also reported that lower physical health among pregnant women corresponded to a lower HRQoL. Among the common health problems experienced during pregnancy, nausea and back pain were the main symptoms associated with lower HRQoL [
17]. A previous study found that pregnant women who participated in an aerobic exercise intervention had improved HRQoL in terms of physical function, pain, and general health domains compared to those who did not participate in the intervention [
22]. However, significant differences in HRQoL were not observed among pregnant women who participated in another fitness intervention involving regular gym exercises compared to pregnant women who did not participate in the program [
23]. According to a previous meta-analysis, moderately intense physical activity improves the quality of life of pregnant women [
24]. Therefore, physical activity for pregnant women should be promoted. Monitoring physical fitness during pregnancy and providing tailored exercise interventions to pregnant women to prevent health problems will be a major factor in improving their HRQoL.
In this study, social support was the second major factor that affected the HRQoL of pregnant women. Previous studies have found the degree of social support to affect the HRQoL of pregnant women [
24]. In addition, HRQoL tends to be lower among pregnant women with no spouse to provide social support [
20]. A lack of emotional support from others can be perceived as rejection, exacerbating the psychological difficulties experienced by pregnant women in the wake of the COVID-19 pandemic. Globally, pregnant women have experienced high rates of depression, anxiety, and isolation during the COVID-19 pandemic, highlighting the importance of connecting with others socially and receiving their support [
25]. Following the advent of the COVID-19 pandemic, interactive social support is urgently needed to ensure the mental health of pregnant women [
26]. Social support is important in terms of both quantity and quality, and counseling from women’s health professionals can be an important source of social support [
27]. Therefore, counseling and support from maternal and child health care professionals in addition to family members should be provided to pregnant women to improve their HRQoL.
In this study, anxiety and depression, as mental health indicators, were not found to be statistically significant factors affecting the HRQoL of pregnant women; however, they still showed a moderate correlation. Lau and Yin [
21] also reported that worse mental health in pregnant women corresponded to a lower HRQoL. The mean score for anxiety among the pregnant women in this study was 9.93 points, with 4 points indicating mild anxiety, 10 to 14 points indicating moderate anxiety, and 15 to 21 points indicating severe anxiety [
13]. The mean score for depression in this study as measured by the PHQ-2 was 2.80 points, indicating depression among the participants according to the instrument’s methodology, which classifies a positive response to any two items as an indicator of depression [
13]. Social functioning, vitality, and emotional role had a moderate association with depression in pregnant women, and pain, physical health, physical functioning, and the physical role had a weak association [
24]. A study of women in advanced countries found that pregnant women with a high level of depression had greater physical and social dysfunction, and nondepressed pregnant women had a better HRQoL than pregnant women with depression [
10]. Prenatal depression was also associated with postpartum depression, suggesting that further efforts should be taken to improve the quality of life of pregnant women with a high level of depression given depression’s impact on pregnant women and their families [
24].
The EQ-5D-3L is a widely used tool for assessing HRQoL, making it easy to compare scores across studies. In this study, the mean EQ-5D-3L score was 1.39, which was close to 1, indicating few problems in the respondents’ HRQoL. In studies of pregnant women by Camacho et al. [
28] and Boutib et al. [
24], the mean scores using the same instrument were 0.89±0.15 and 0.71±0.24, respectively, both of which were lower than the mean score in this study. A score range of 0.81-0.99 was reported in a 20-country wide-ranging survey of the general population [
29]. The EuroQol VAS has been reported to range from 70.4 to 83.3 points. The EuroQol VAS score in this study was 73.04 points, which is similar. Therefore, the physical health status and HRQoL of pregnant women in this study were lower than those of women in general [
30]. This finding is consistent with the finding that HRQoL is generally lower among pregnant women than among nonpregnant women and the population in general, especially in terms of the mental and physical domains of HRQoL [
24].
In this study, we found that pregnant women, who are particularly vulnerable in the wake of the COVID-19 pandemic, experienced low social support, depression and anxiety, poor mental health, poor physical health status, and a decreased HRQoL. A longitudinal study of 12,007 pregnant women from 2020 to 2022 reported that increases in depression, anxiety, and stress coincided with timing of COVID-19 case surges [
30]. Depression reportedly increased by 27.6% during the pandemic, while anxiety increased by 25.6%; younger people and women were more strongly affected, and less human mobility was associated with worse mental health [
31]. Therefore, we also identified social support and physical health status as factors that affect the HRQoL of pregnant women. Therefore, to improve the HRQoL of pregnant women, maternal and fetal health professionals should strengthen their social support through counseling and implement interventions incorporating exercise and other activities to improve their physical health status.
This study has some limitations. First, it was conducted with pregnant women in the regions of Gangwon and Chungcheongnam Province only, and the participants were from rural areas rather than urban areas; therefore, caution should be exercised when generalizing the study results. Additionally, this study used self-reported surveys, which may have skewed the results since they did not reflect the objective health status of the women determined via direct measurement. In addition, due to the nature of the survey, which required the ability to read and write in Korean, it was impossible to include women of other ethnicities and races who may not have understood Korean.
Based on the findings of this study, we recommend conducting further surveys to identify the factors that influence the HRQoL of pregnant women across various regions. In particular, we suggest conducting a study to determine the factors that influence the HRQoL of pregnant women in different areas and compare the differences in anxiety, depression, social support, physical health status, and HRQoL between the prenatal and postnatal periods.