The investigation of changes in health-related quality of life before and after giving birth in a sample of Romanian women

Pregnancy is an important and meaningful period of transition to motherhood. It can be seen as a socially, physically, psychologically, and culturally challenging and transformative period, and may affect women’s physical and mental health. Objectives of this study are to investigate significant differences in health-related quality of life and indicators of mental health in women during pregnancy and after giving birth and to explore the association patterns between these variables during pregnancy and after giving birth. The study included 57 Romanian women enrolled from July 2019 until the end of April 2020 through Facebook groups dedicated to pregnant women and mothers, forums, and support groups. The women completed the set of questionnaires twice: during pregnancy and one month after giving birth. The participants reported significantly lower levels of depressive symptoms in the second semester of pregnancy compared to the assessment conducted one month after giving birth. Physical functioning, affectionate expression, and vitality proved to significantly improve after giving birth. Emotional well-being, social functioning, and cohesion seem to lower significantly after giving birth. The results of the study can be used as a basis for designing, planning, and implementing appropriate interventions for women by healthcare providers and policymakers. indicated that in the second trimester of pregnancy, the physical functioning component of the health-related quality of life presented no significant association patterns with the assessed variables, while after giving birth, this variable became strongly associated with the affectional expression ( r (43) = .27, p < .01) and cohesion ( r (43) = .42, p < .01) components of the marital satisfaction scale. Role limitations due to physical health presented a weak negative correlation with depressive symptoms in the second trimester before giving birth ( r (40) = -.36, p < .05), while one month after giving birth it positively correlated with marital satisfaction (r(42) = .32, p < .05) and cohesion ( r (42) = .31, p < .01). p < .01), marital satisfaction ( r (42) =.35, p < .05) and cohesion ( r (42) = .38, p < .05), while one month after giving birth vitality presents a significant negative association with depressive symptoms ( r (43) = -.86, p < .01), loneliness ( r (43) = -.71, p < .01), positive association with consensus ( r (43) = .39, p < .01), marital satisfaction ( r (43) = .41, p < .01), and self-esteem ( r( 43) = .47, p < .01). Our results indicate that emotional well-being in the second trimester of pregnancy is negatively associated with depression ( r (41) = -.65, p <.01), loneliness ( r (41) = -.59, p < .01), and positively with self-esteem (r(43)=.56, p < .01), marital consensus ( r (32)=.69, p < .01), marital satisfaction ( r (42) = .71, p < .01), and cohesion ( r (42) = .66, p < .01). One month after giving birth, emotional well-being presented significant negative correlation with depression ( r (43) = -.86, p < .01), loneliness ( r (43) = -.71, p < .01), and positively with self-esteem ( r (43) = .47, p < .01), consensus ( r (43) = .39, p < .01), marital satisfaction ( r (43) = .41, p < .01), and cohesion ( r (43) = .40, p < .01). The social functioning component of the subjective well-being scale presents a single significant association pattern, during pregnancy, namely negative correlation with depression ( r (41) = -.51, p < .01). The general health subscale of the SF-36 reported a significant negative correlations with depressive symptoms ( r (44) = -.40, p < .01), loneliness ( r (42) = -.43, p < .01), and positive associations with marital satisfaction (


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South-West University "Neofit Rilski" 2022, Vol. 15(1), 165-188 https://doi.org/10.37708/psyct.v15i1.638 promote the development of mental conditions, such as difficulties in managing anger, depression, anxiety, and interpersonal relationships (Santos et al., 2016). During pregnancy, approximately 9-13% of the women experience depression, and 13-15% of them experience anxiety (McLeish & Redshaw, 2017). Moreover, depressed women are more likely to report loneliness which is predicted to have a constant trajectory over a long period of depressive symptoms (Rokach, 2007). This leads to lower self-esteem which might determine a woman to neglect her own health and the health of her child(ren), and may occasionally lead to emotional and physical abuse (Mandai et al., 2018). Maternal stress has a negative effect and a long-term influence on the development of the unborn, leading to future socio-emotional problems, higher negative emotionality, an increased rate of behavioral problems (substance use and abuse), poor emotional regulation, and high risk for developing anxiety disorders (Howard et al., 2014;Weis & Renshon, 2019;Zietlow et al., 2019).
Women are more likely to experience depression and anxiety during pregnancy and in the postnatal period if they: (1) feel socially isolated, feel like they have low social and emotional support in general, (2) have no partner, (3) have low income, or (4) are aged under 20 years (Lucas et al., 2019;Satyanarayana et al., 2011). One of the strongest predictors of depressive symptoms is a history of depression (Satyanarayana et al., 2011). Other risk factors for depressive symptoms are adjustment to motherhood, limited social activities, previous fetal loss, difficulties in pregnancy and actual concerns about the pregnancy (Furber et al., 2009), lack of support given by the partner, being a single mother, previous history of still birth, and a low quality of marital relationship (Adewuya et al., 2007).
The quality of the relationship with the partner is very important and it depends on certain factors. Depressive symptoms and social support have been found to be significant factors of health-related quality of life among pregnant women (Liu et al., 2013). Furthermore, poor emotional health of pregnant women was associated with an increased number of prenatal visits, fetal surveillance, and more frequent use of hospital resources (Liu et al., 2013). A lower level of social and physical functioning has been associated with a higher risk of preterm birth and/or low birth-weight infants (Liu et al., 2013). Perceived stress of both partners was associated with a low level of dyadic consensus and affectional expression (Baldoni et al., 2020). Partners experiencing high levels of stress are more likely to be less satisfied with their relationship, tend to report less agreement and emotional affection (Baldoni et al., 2020).

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South-West University "Neofit Rilski" 2022, Vol. 15(1), 165-188 https://doi.org/10.37708/psyct.v15i1.638 During pregnancy some factors were significantly associated with the quality of life of pregnant women: poor emotional functioning, depressive symptoms, sociodemographic characteristics (race-African-American), social support, clinical conditions on health-related quality of life (Nicholson et al., 2006), adverse pregnancy histories (fetal death, repeated spontaneous abortion, preterm deliveries, early neonatal deaths) (Couto et al., 2009), physical functioning (health problems influence daily activities), role-physical (everyday roles, such as work, are negatively influenced by problems in physical health), bodily pain, social functioning (health problems interfere with social activities), role-emotional (everyday roles, such as work, are negatively influenced by emotional problems) (Hama et al., 2008), problems with diet or treatment regimens, sleep problems, irritability, disturbed body image, skin changes (striae, melasma), urinary frequency, heart burn, stomach pain, concerns related to the child's gender (due to sociocultural context, as some societies manifest preference for a male child), childbirth related concerns (delivery pain, problems with natural delivery, fear of the unknown and fear for episiotomy, negative experiences with the delivery process, intra-delivery death, vaginal examination, the use of forceps and vacuum, the risk of damage and complications to both mother and baby) (Kazemi et al., 2017).
In the postpartum period, research indicated that there were several factors that correlated with quality of life: emotional role, physical role, education (secondary or university), the parity, health problems during pregnancy (high blood pressure, nausea, anxiety and gestational diabetes), caesarean section, third/fourth degree perineal tears while giving birth, involved episiotomy, premature newborn, the mother being admitted to an intensive care unit, hospital readmission, the newborn being hospitalized, the gestational age of women at the moment of giving birth, babies feeding type (formula or breast-fed), having a lower quality of life before pregnancy, the mode of delivery (emergency caesarean section and caesarean section due to medical indication affected the quality of life years after giving birth), illness, breastfeeding difficulties, problems in the romantic relationship (Morin et al., 2017).

Objectives
The present study derived its objectives from the findings, according to which pregnant women's mental health and quality of life depend on a large number of intra-and interpersonal factors that further affect the way they adapt to the challenges of birth and the way they take care of the newborn. As Martínez-Galiano et al. (2019) suggested, there is a plethora of studies that investigate specific aspects of different stages of pregnancy, birth, and the postpartum period,
Thus, the first objective of the present study was to investigate whether there were significant differences in health-related quality of life and indicators of mental health in women during pregnancy and after giving birth. The second objective was to investigate the association patterns between these variables during pregnancy and after giving birth.

Method & Procedure Participants
The enrollment of the participants began in July 2019 and continued until the end of April 2020.
It took place through 94 Facebook groups dedicated to pregnant women and mothers, forums, and support groups. A total of 320 persons were interested in the study, of which 220 (68.75%) participants passed the screening stage (completed the first assesment during pregnancy).
Those who did not meet the criteria of eligibility (Romanian residence, age above 18 years, being pregnant) were excluded. Finally, the study included 57 Romanian women who were eligible (completed the assesment during pregnancy and the assesment one month after birth), with a mean age of 29.27 years (SD = 4.79, min = 20, max = 38) who met all the inclusion criteria and completed the set of questionnaires twice: during pregnancy and one month after giving birth. After providing an online informed consent, participants completed the online questionnaire packets that took 25 minutes to fill. The present research received the approval of the Committee of the Department of Psychology (Babes-Bolyai University) by being coordinated by one of its employees.  (Beck et al., 1979). BDI is a 21-item scale developed for assessing the severity of depression in normal and psychiatric populations (Hubley, 2014 Pregnancy-related anxiety was measured with the Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2) (Huizink et al., 2016). Participants were asked to report for each statement their response on a 5-point Likert scale from "Absolutely irrelevant" to "Very relevant". Three subscales were developed: 1) the fear of giving birth, 2) concerns about having a child with a disability, and 3) concerns about one's own appearance. Cronbach's alpha scores were good for the entire scale, having coefficients above .80, which means that PRAQ-R2 has a good reliability level. For the present sample, the internal consistency indices for the PRAQ-R2 were .88 (number of items = 10).

Instruments
Health-related quality of life was assessed with the Health-related Quality of Life-Short Form Scale 36, a very popular tool for assessing health-related quality of life (SF-36) (Ware et al., 1980). SF-36 comprises eight scales: physical functioning, physical role, body pain, general health, vitality, social functioning, emotional role, and mental health (Ware et al., 1980). SF-36 was estimated to have a reliability score above 0.70, although scores can vary depending on the sample population (Gandek al al., 2004). For the present sample, the internal consistency indices for the SF-36 were .84 (number of items = 36).

Marital satisfaction and adjustment was measured with the 32-item Dyadic Adjustment Scale
(DAS) (Spanier, 1976). Participants had to rate their answers on a 6-point Likert scale consisting of ranging from "always agree" to "always disagree". The scale has four subscales: Dyadic Consensus (the degree to which the couple agrees with important aspects of the relationship), Dyadic Satisfaction (the degree to which the couple is satisfied with their relationship), Dyadic Cohesion (degree of closeness and shared activities experienced by the couple) and Affective Expression (degree of demonstrations of affection and sexual relations).
For the present sample, the internal consistency indices for the DAS were .83 (number of items = 32).
Self-esteem was measured with the Rosenberg Self-esteem scale (Rosenberg, 1965) (GSES-Romanian Adaptation - Băban et al., 1989). The SES measures self-esteem as a onedimensional construct (Rosenberg, 1965). This is a 10-item scale that measures overall selfworth and includes both positive and negative feelings about oneself. Higher scores (of each subscale, as well as of the total score) indicate a higher self-esteem. For the present sample, the internal consistency indices for the SES were .87 (number of items = 10).

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South-West University "Neofit Rilski" 2022, Vol. 15(1), 165-188 https://doi.org/10.37708/psyct.v15i1.638 Loneliness was measured with the UCLA Loneliness Scale, Version 3 (Russell et al., 1980). UCLA is a scale of 20 items designed to measure subjective feelings of loneliness and feelings of social isolation. Participants rate each item on a scale of 1 (Never) to 4 (Often) (Russell et al., 1980). UCLA loneliness scale has a very good internal consistency, the alpha coefficient ranging from 0.89 to 0.94. It also has a good test-retest reliability, with a coefficient of .73. For the present sample, the internal consistency indices for the UCLA were .91 (number of items = 20).

Data Analysis
The data collected through the first assessment during pregnancy and the second assessment after giving birth (one month) was analyzed with the "SPSS 20 Statistics" program. Descriptive analysis were performed for pointing out the characteristics of collected data. A paired-samples t-test was applyed in order to compare the results of the same sample of pregnant women (N = 57) in the two temporal moments (prenatal and postnatal) for loneliness, depression, selfesteem, marital satisfaction, and quality of life. Also, it was assessed the association patterns between all the variables during pregnancy and after giving birth by using correlation analyses.

Results
The descriptive characteristics of the data are presented in Table 1.
The investigation was continued by comparing the assessed variables before and after giving birth. Since most of the data did not follow a normal distribution, the Wilcoxon non-parametric paired-samples t-test was performed. Effect size was calculated according to the formula: r=Z/√N (Rosenthal, 1994). Significant differences are presented in Table 2.

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South-West University "Neofit Rilski" 2022, Vol. 15 (1) As seen in Table 2, the results indicate statistically significant differences in depressive symptoms between the two assessments. More specifically, the assessed participants reported significantly lower levels of depressive symptoms in the second semester of pregnancy In what concerns the correlation, an analysis between all variables in the period during pregnancy was conducted and the significant results obtained between a series of variables, were reported according to the significance level of .01 and .05 (Results are presented in Table   3).  Results indicated that in the second trimester of pregnancy, the physical functioning component of the health-related quality of life presented no significant association patterns with the assessed variables, while after giving birth, this variable became strongly associated with the affectional expression (r(43) = .27, p < .01) and cohesion (r(43) = .42, p < .01) components of the marital satisfaction scale. Role limitations due to physical health presented a weak negative correlation with depressive symptoms in the second trimester before giving birth (r(40) = -.36, p < .05), while one month after giving birth it positively correlated with marital satisfaction (r(42) = .32, p < .05) and cohesion (r(42) = .31, p < .01).
Role limitations due to emotional problems before birth negatively correlate with loneliness .37, p < .05) and cohesion (r(42) = .36, p < .05) during pregnancy. One month after giving birth, general health negatively correlates with loneliness (r(43) = -.51, p < .01), positively with marital consensus (r(43) = .32, p < .05), and marital satisfaction (r(43) = .34, p < .05). Finally, pain presents no significant correlations with any of the assessed variables in the second trimester of pregnancy, while one month after giving birth it is weakly associated only with marital satisfaction (r(43) = .31, p < .05). birth, as well as the result of the comparison of the correlation coefficients (Z) (based on Steiger, 1980). As the results indicated, within the sample there existed some similarities in the correlation patterns during pregnancy (T 1 ) and after giving birth (T 2 ) (as seen in Table 5). However, it was found significant differences between the strength of some of these associations. Thus, even if both at T 1 and T 2 vitality significantly correlates with depressive symptoms, this association is significantly stronger at T 2 than at T 1 (Z = -2.57, p < .01). The same pattern may be found in the case of loneliness, where associations with vitality are significantly stronger at T 2 than at T 1 (Z = -2.04, p < .05). Further on, emotional well-being is significantly correlated with depression both at T 1 and T 2 , but the association is significantly stronger at T 2 than at T 1 (Z = -2.31, p < .01).
Emotional well-being is also significantly correlated with two of the components of the marital satisfaction scale, and in both cases the correlation is significantly stronger at T 1 than at T 2 : consensus (Z= 1.97, p < .05) and satisfaction (Z = 2.04, p < .05).

Discussion
The first objective of the current study was to investigate whether there were significant differences in health-related quality of life and indicators of mental health in women during pregnancy and after giving birth. The results indicated that depressive symptoms significantly increased from pre-to postnatal assessments, results that are in line with previous findings.
Studies indicate that approximately 10% of women develop postpartum depression in the first weeks after giving birth (Cooper & Murray, 1998) and 15 to 85% have postpartum blues, which include mood swings, irritability, sadness, fatigue (Pearlstein et al., 2009). Another study discovered that the percentage of women with clinical depression after birth was slightly higher (10.4%), than before pregnancy (8.7%) and during pregnancy (6.9%) (Dietz et al., 2007). Other significant differences between the two assessments were observed in what concerns the quality of life variables (SF-36). More specifically, physical functioning and vitality were the aspects of quality of life which improved after giving birth. One possible explanation for this improvement is that during pregnancy most women go through symptoms of nausea and vomiting, which affect the quality of life of the pregnant woman (Lacasse et al., 2008). These findings are also supported by the fact that during pregnancy the metabolism goes through a lot Psychological Thought South-West University "Neofit Rilski" 2022, Vol. 15(1), 165-188 https://doi.org/10.37708/psyct.v15i1.638 of changes, the urinary system is affected, along with the respiratory system and the genital organs (Calou et al., 2018). Emotional well-being recorded significant decreases from prenatal to postnatal evaluation. One important aspect related to emotional well-being is the social support that the pregnant woman receives, therefore if she feels supported by her partner, family or friends, it is more likely that she will feel better emotionally (McLeish & Redshaw, 2017). Regarding social support, our study indicates that pregnant women also felt more cohesive with their partner and family during pregnancy than after they gave birth. Social cohesion seems to work like a buffer between poor social support and psychological distress (Yamada et al., 2021).
Cohesion along with affectionate expression are marital satisfaction variables. While cohesion decreased after giving birth, affectionate expression increased after birth. Regarding affectionate expression, women were more prone to express affection after they gave birth and they also felt more satisfied with their marriage after having their baby. These results are confirmed by other studies, suggesting that the dynamics of the new parents have a big impact over marital satisfaction. If the partner was sensitive and paid attention to the mother, to the baby and the relationship, and also if the woman felt being present in their relationship, then marital satisfaction increased or remained stable (Shapiro et al., 2000).
Also, women had better social functioning during pregnancy than after birth. This may be, in part, because after giving birth, the new mothers do not have the time and energy to engage in social activities (Haas et al., 2005). Although compared to nonpregnant women, in pregnancy there are observed declines in social functioning (Otchet et al., 1999), but the severity of the decline is influenced by more factors, such as the household income, marital status, the number of times the woman gave birth, multiparity being related to a lower social functioning, as well as pregnancy complications and pregnancy anxiety (Da Costa et al., 2010).
The second objective was to investigate the association patterns between these variables during pregnancy and after giving birth. During pregnancy, we can observe a positive association between vitality and self-esteem and between vitality and marital satisfaction. As the level of vitality increases, so does the level of self-esteem and marital satisfaction. On the other hand, we identified a negative association between vitality and depression and loneliness. As the level of vitality decreases, the symptoms of depression and loneliness increase. Studies show that maintaining physical activities during pregnancy, even in a lesser degree, contributes to physical well-being and a sense of enjoyment (Hegaard et al., 2010). The emotional wellbeing was negatively associated with depressive symptoms and with loneliness. Also, emotional well-being was positively associated with self-esteem and marital satisfaction. Emotional wellbeing is stronger associated with marital consensus and satisfaction during pregnancy than after giving birth. Based on a study published in 2006, emotional well-being seemed to improve during pregnancy for women who went through positive changes regarding their self-efficacy for labor and delivery (Sieber et al., 2006).
Role limitations due to emotional problems were negatively associated with loneliness and positively associated with marital consensus, affectionate expression, marital satisfaction, and cohesion. As role limitations due to emotional problems decreased, marital satisfaction overall increased. When talking about role limitations due to physical health, they were negatively associated with depressive symptoms. Physical symptoms present during pregnancy, such as nausea and vomiting, along with sleep problems might limit women's activities, affecting their health status, including emotional health (Da Costa et al., 2010). Social functioning was identified to be negatively associated with depressive symptoms. Nonetheless, the general health of the pregnant woman was negatively associated with depressive symptoms and the feelings of loneliness and positively associated with marital satisfaction and cohesion.
After giving birth, vitality was negatively associated with depressive symptoms and feelings of loneliness and positively associated with self-esteem, consensus, and marital satisfaction. As shown in the literature, vitality levels declined during pregnancy and remain at similar levels after giving birth (Nicholson et al., 2006). Based on this research results this association, even though is present during pregnancy too, it is stronger after giving birth. It may be because women usually feel more tired after giving birth than during pregnancy (Henderson et al., 2019).
Also, emotional well-being was negatively associated with depressive symptoms and loneliness and positively associated with self-esteem, marital consensus, satisfaction, and cohesion. In the present study, the association between emotional well-being and depressive symptoms seemed to be stronger after giving birth than during pregnancy. In what concerns role limitations due to emotional problems, they were negatively associated with depressive symptoms, feelings of loneliness, marital satisfaction, and cohesion.
In what concerns the general health after pregnancy, it was negatively associated with loneliness and positively associated with marital satisfaction and consensus. Physical

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South-West University "Neofit Rilski" 2022, Vol. 15(1), 165-188 https://doi.org/10.37708/psyct.v15i1.638 functioning was positively associated with affectionate expression and cohesion. Also, role limitations due to physical health were positively associated with marital satisfaction and cohesion. Studies show that physical functioning is at its best after conception, then it declines, but it improves after giving birth (Haas et al., 2005). There are certain factors that may affect the health status of the women after giving birth, such as poor social support, lack of exercise during pregnancy, pregnancy factors (Caesarian section), financial problems (Haas et al., 2005).

Limitations and further implications
The study has certain limitations. The questionnaires were completed using a self-report method and the data might not be reliable. Another limitation is the small sample size and the fact that we included only women who had internet access to complete the questionnaires online. More measurements are needed to precisely examine changes in health-related quality of life before and after giving birth. Future studies are needed to test our results in a bigger and more diverse sample of pregnant women. Furthermore, a qualitative research design can be approached to explore the health-related quality of life pregnant women and gain a better understanding of the subject. The results of our study can be used as a basis for designing, planning, and implementing appropriate interventions to enhance the health-related quality of life of women by healthcare providers and policymakers. By providing these services, the physical and emotional health of the mother and the baby can be influenced positively.

Conclusions
Some of the findings of the study highlight the fact that in the postnatal period, the participants reported a higher level of depressive symptoms, a decrease in the emotional well-being and social functioning, while during pregnancy, the participants reported a higher level of physical functioning and vitality. Moreover, women in the sample reported a decrease in the level of cohesion after birth but an increase in the affectionate expression.