The effects of maternal health literacy, family functioning and self-efficacy on antepartum depression in pregnant women in China: a moderated mediation model
Depression is a leading cause of disease-related disability in women globally . Pregnant women are more prone to depression due to hormonal changes and the pressure caused by pregnancy and birth . It is estimated that 20.7% of pregnant women experience antepartum depression (AD) . A growing number of studies have shown that the prevalence of AD is greater than that of postnatal depression (PD) . In China, related studies have reported that the prevalence of AD is approximately 5.19% ~ 44.7% . AD has harmful effects on both mothers and fetuses, increases the risk of negative outcomes , and can affect the biosocial adaptation of spousal, family, and community relationships . AD is often considered to be a predictor of preterm birth, miscarriage, fetal growth restriction, and increased rates of PD . Women who experience depression during pregnancy are at greater risk of having offspring with behavioral/emotional problems in childhood . Therefore, AD has received increasing attention from researchers and has become the focus of public health research in recent years. The field of maternal and child health is also shifting from preventing PD to improving women's mental health during pregnancy. Numerous factors affect the development of AD, such as sociodemographic characteristics, including maternal age, marital status, education level, and income level, as well as social support, family functioning (FF) and self-efficacy (SE) . FF is defined as the coordinating role that a family plays in meeting the survival, safety, and social needs of its members. It is manifested in mutual care, mutual support, and emotional communication among family members . Positive family functioning can enhance adaptive coping behavior, which is crucial for the management of emotions . The literature indicates that FF, which has a direct negative correlation with depression and has a significant predictive effect on depression, is the key component of social support . In addition, FF can influence depression through SE. SE refers to an individual's belief in their own ability to accomplish a goal . People who have high SE usually experience fewer problems with their physical and mental health and can deal with events and conditions more easily and effectively . Some studies have shown that increasing SE may reduce depression . It might be a protective factor against mental health problems . Health literacy (HL) is generally defined as the ability of an individual to obtain, process, and understand basic health information and services to make appropriate health decisions . It is considered to be the most important factor in determining health  and one of the most fundamental, economical and effective measures to improve the health level of the whole population. At present, an increasing number of studies are investigating the relationship between HL and depression, mainly focusing on diabetes and cardiovascular diseases . Most studies have shown that HL is negatively associated with the incidence of depression , whereas some studies have reported no relationship between HL and depression . Little research has been reported on the relationship between maternal health literacy (MHL) and AD. Overall, previous studies have explored the relationships between any one or two of the above factors and AD, but there has been little research on MHL and AD and the relationships among these four variables. Moreover, there is relatively little understanding of the synergistic effect or potential underlying mechanisms of these factors on AD. Therefore, the purpose of this study was to construct a structural equation model (SEM) to explore the relationships among AD, MHL, FF and SE and reveal the relationship between FF and AD and whether this relationship is mediated by MHL and SE, which can provide a theoretical basis and intervention ideas to improve AD.   Study Design and Participants Chongqing is divided into central districts and towns according to the Chongqing Health Statistics Yearbook 2022. This cross-sectional survey was conducted from September 2023 to February 2024 at six hospitals in Chongqing, with 3 hospitals each in the central urban district and town groups. Using a convenience sampling method, pregnant women who received antenatal care at these hospitals and met the following criteria were recruited: (1) aged at least 18 years, (2) permanently resided in Chongqing, (3) had a singleton pregnancy, and (4) had no cognitive dysfunction or previous history of mental disorders. The study scope and purpose were explained to the patients, and written informed consent was obtained from patients who met the inclusion criteria prior to their participation in the investigation. The investigators were the nursing staff from the respective hospitals. For illiterate participants, answers to the questionnaire were collected through face‒to-face interviews, and literate participants completed self-administered questionnaires. After all incomplete and invalid questionnaires were excluded, 1392 pregnant women were included in this study. Instruments General information questionnaire The questionnaire collected the general information of the pregnant women, including their age, educational level, occupation type, monthly income, week of gestation, unplanned pregnancy status, sleep status, health status, marital relationship, and whether they had gone to maternity school. Maternal health literacy The MHL questionnaire was developed and compiled by the China Maternal and Child Health Care Association in accordance with Article 55 of Basic Knowledge and Skills of Maternal and Child Health Literacy . This questionnaire consists of 35 questions, covering key health points such as nutrition and exercise during pregnancy, weight control, delivery methods, breastfeeding, and newborn care. It is divided into three dimensions: (1) basic knowledge of mothers and infants (BKMI, 22 items), (2) behaviors and lifestyle (BAL, 8 items), and (3) health-related skills (HRS, 5 items). A score of 0 is given for a wrong answer. The overall health literacy score ranges from 0 to 100 points. Participants who obtain a total score of 60% or higher (≥ 60 points) were considered to have adequate HL. Self-efficacy SE was measured via the General Self-Efficacy Scale (GSES) developed by Schwarzer  and translated into Chinese by Wang Caikang . This scale consists of 10 items, each of which is scored using a 4-point Likert scale. The higher the score is, the stronger the SE. The Chinese version has high sensitivity and validity, and the Cronbach’s α coefficient is 0.85 . Family Functioning The family adaptation partnership growth affection and resolve (APGAR) index was designed by Smilkstein  and has been translated into Chinese . It has been widely used in China and has good reliability and validity . The APGAR index contains five items ranging from 0 (rare) to 2 (often) and reflects five aspects: adaptation, partnership, growth, affection, and resolve. The total score ranges from 0–10 points. Higher scores indicate better family care, with a score of 0–3 indicating poor, 4–6 indicating fair, and 7–10 indicating good family functioning . In this study, the Cronbach's alpha coefficient for the Family APGAR Index was 0.912. Antepartum depression AD was evaluated on the basis of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) developed by Lee et al. at the Chinese University of Hong Kong ; the EPDS has been applied by scholars in many countries to screen for AD and depression in other populations , with an internal consistency reliability of 0.76 and content validity of 0.93. The scale contains 10 items, each scored on a scale ranging from 0 to 3. The total score ranges from 0 to 30 points. In previous Chinese studies, a score of 10 or above was commonly utilized. For the purpose of facilitating comparison, we selected this relatively lower cut—off score of 10 or higher . In the present study, the Cronbach’s α of EPDS was 0.851. Statistical analyses All of the data were entered into a database in Epidata version 3.02 and analyzed with SPSS 26.0 software. Categorical variables are presented as numbers and percentages. Continuous variables are presented as the means ± standard deviations and medians. Pearson correlation was computed to describe the associations between variables if they were normal, and Spearman correlation analysis was used otherwise. IBM SPSS AMOS 22.0 was used to establish the SEM. The SEM used bootstrap maximum likelihood estimation, and a p value < 0.05 was considered statistically significant. The model was constantly refined and re-estimated to verify the model fit and to select the best-suited model. The following indices were used to evaluate the goodness of fit of the model: the comparative fit index (CFI), adjusted goodness-of-fit index (AGFI), goodness-of-fit index (GFI), normed fit index (NFI), incremental fit index (IFI), and root mean square error of approximation (RMSEA).   Chongqing is divided into central districts and towns according to the Chongqing Health Statistics Yearbook 2022. This cross-sectional survey was conducted from September 2023 to February 2024 at six hospitals in Chongqing, with 3 hospitals each in the central urban district and town groups. Using a convenience sampling method, pregnant women who received antenatal care at these hospitals and met the following criteria were recruited: (1) aged at least 18 years, (2) permanently resided in Chongqing, (3) had a singleton pregnancy, and (4) had no cognitive dysfunction or previous history of mental disorders. The study scope and purpose were explained to the patients, and written informed consent was obtained from patients who met the inclusion criteria prior to their participation in the investigation. The investigators were the nursing staff from the respective hospitals. For illiterate participants, answers to the questionnaire were collected through face‒to-face interviews, and literate participants completed self-administered questionnaires. After all incomplete and invalid questionnaires were excluded, 1392 pregnant women were included in this study.   General information questionnaire The questionnaire collected the general information of the pregnant women, including their age, educational level, occupation type, monthly income, week of gestation, unplanned pregnancy status, sleep status, health status, marital relationship, and whether they had gone to maternity school. Maternal health literacy The MHL questionnaire was developed and compiled by the China Maternal and Child Health Care Association in accordance with Article 55 of Basic Knowledge and Skills of Maternal and Child Health Literacy . This questionnaire consists of 35 questions, covering key health points such as nutrition and exercise during pregnancy, weight control, delivery methods, breastfeeding, and newborn care. It is divided into three dimensions: (1) basic knowledge of mothers and infants (BKMI, 22 items), (2) behaviors and lifestyle (BAL, 8 items), and (3) health-related skills (HRS, 5 items). A score of 0 is given for a wrong answer. The overall health literacy score ranges from 0 to 100 points. Participants who obtain a total score of 60% or higher (≥ 60 points) were considered to have adequate HL. Self-efficacy SE was measured via the General Self-Efficacy Scale (GSES) developed by Schwarzer  and translated into Chinese by Wang Caikang . This scale consists of 10 items, each of which is scored using a 4-point Likert scale. The higher the score is, the stronger the SE. The Chinese version has high sensitivity and validity, and the Cronbach’s α coefficient is 0.85 . Family Functioning The family adaptation partnership growth affection and resolve (APGAR) index was designed by Smilkstein  and has been translated into Chinese . It has been widely used in China and has good reliability and validity . The APGAR index contains five items ranging from 0 (rare) to 2 (often) and reflects five aspects: adaptation, partnership, growth, affection, and resolve. The total score ranges from 0–10 points. Higher scores indicate better family care, with a score of 0–3 indicating poor, 4–6 indicating fair, and 7–10 indicating good family functioning . In this study, the Cronbach's alpha coefficient for the Family APGAR Index was 0.912. Antepartum depression AD was evaluated on the basis of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) developed by Lee et al. at the Chinese University of Hong Kong ; the EPDS has been applied by scholars in many countries to screen for AD and depression in other populations , with an internal consistency reliability of 0.76 and content validity of 0.93. The scale contains 10 items, each scored on a scale ranging from 0 to 3. The total score ranges from 0 to 30 points. In previous Chinese studies, a score of 10 or above was commonly utilized. For the purpose of facilitating comparison, we selected this relatively lower cut—off score of 10 or higher . In the present study, the Cronbach’s α of EPDS was 0.851.   The questionnaire collected the general information of the pregnant women, including their age, educational level, occupation type, monthly income, week of gestation, unplanned pregnancy status, sleep status, health status, marital relationship, and whether they had gone to maternity school.   The MHL questionnaire was developed and compiled by the China Maternal and Child Health Care Association in accordance with Article 55 of Basic Knowledge and Skills of Maternal and Child Health Literacy . This questionnaire consists of 35 questions, covering key health points such as nutrition and exercise during pregnancy, weight control, delivery methods, breastfeeding, and newborn care. It is divided into three dimensions: (1) basic knowledge of mothers and infants (BKMI, 22 items), (2) behaviors and lifestyle (BAL, 8 items), and (3) health-related skills (HRS, 5 items). A score of 0 is given for a wrong answer. The overall health literacy score ranges from 0 to 100 points. Participants who obtain a total score of 60% or higher (≥ 60 points) were considered to have adequate HL.   SE was measured via the General Self-Efficacy Scale (GSES) developed by Schwarzer  and translated into Chinese by Wang Caikang . This scale consists of 10 items, each of which is scored using a 4-point Likert scale. The higher the score is, the stronger the SE. The Chinese version has high sensitivity and validity, and the Cronbach’s α coefficient is 0.85 .   The family adaptation partnership growth affection and resolve (APGAR) index was designed by Smilkstein  and has been translated into Chinese . It has been widely used in China and has good reliability and validity . The APGAR index contains five items ranging from 0 (rare) to 2 (often) and reflects five aspects: adaptation, partnership, growth, affection, and resolve. The total score ranges from 0–10 points. Higher scores indicate better family care, with a score of 0–3 indicating poor, 4–6 indicating fair, and 7–10 indicating good family functioning . In this study, the Cronbach's alpha coefficient for the Family APGAR Index was 0.912.   AD was evaluated on the basis of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) developed by Lee et al. at the Chinese University of Hong Kong ; the EPDS has been applied by scholars in many countries to screen for AD and depression in other populations , with an internal consistency reliability of 0.76 and content validity of 0.93. The scale contains 10 items, each scored on a scale ranging from 0 to 3. The total score ranges from 0 to 30 points. In previous Chinese studies, a score of 10 or above was commonly utilized. For the purpose of facilitating comparison, we selected this relatively lower cut—off score of 10 or higher . In the present study, the Cronbach’s α of EPDS was 0.851.   All of the data were entered into a database in Epidata version 3.02 and analyzed with SPSS 26.0 software. Categorical variables are presented as numbers and percentages. Continuous variables are presented as the means ± standard deviations and medians. Pearson correlation was computed to describe the associations between variables if they were normal, and Spearman correlation analysis was used otherwise. IBM SPSS AMOS 22.0 was used to establish the SEM. The SEM used bootstrap maximum likelihood estimation, and a p value < 0.05 was considered statistically significant. The model was constantly refined and re-estimated to verify the model fit and to select the best-suited model. The following indices were used to evaluate the goodness of fit of the model: the comparative fit index (CFI), adjusted goodness-of-fit index (AGFI), goodness-of-fit index (GFI), normed fit index (NFI), incremental fit index (IFI), and root mean square error of approximation (RMSEA).   Baseline characteristics A total of 1500 participants were enrolled in the survey; 1422 agreed to participate and returned questionnaires, for a response rate of 94.80%. Thirty questionnaires were excluded because of invalid or incomplete responses; thus, 1392 valid questionnaires were included in the analysis, indicating an effective rate of return of 97.89%. The demographic characteristics of the included participants are shown in Table . The responders were aged 18–44 years, with an average age of 29.63 ± 4.14 years. Most of them were Han (87.14%), were married (97.34%), and had a high school education or above (86.78%). The majority of the participants were currently employed (73.28%) and had medical insurance (75.22%). The proportions of primigravidas and multiparous women were 55.68% and 44.32%, respectively. Most of them did not attend pregnancy school (61.64%). More than half of the participants had good sleep (67.24%), and most of the participants were in good health (72.27%). Descriptive statistics for the measured variables Table shows the means and standard deviations of the study variables. The mean depression score was 7.60 ± 4.40 points. A total of 31.90% (444) of the participants had depression, whereas 68.10% (948) of the participants experienced no depression. The mean MHL, FF, and SE scores were 43.71 ± 19.54, 7.16 ± 2.78 and 26.07 ± 6.56 points, respectively. There were statistically significant differences in MHL, FF and SE between the depressed and nondepressed groups, as shown in Table . Table shows the results of the correlation analyses of MHL, FF, SE and AD. AD was negatively correlated with MHL, FF and SE ( p < 0.01). MHL was positively correlated with SE ( p < 0.01) but not with FF ( p > 0.01). There was a positive correlation between FF and SE ( p < 0.01). Measurement model MHL, SE and FF were associated with AD, and we utilized an SEM to design a mediating model. According to the research hypothesis, a path analysis diagram of the whole model was established. However, the relationship between MHL and FF was not statistically significant. Therefore, we eliminated the direct route to better fit the structural model. Figure shows the final model with standardized path coefficients, which had an adequate fit (Table ). The results revealed that there were significant correlations between the observed variables and their corresponding latent variables (most of the regression weights were greater than 0.7). Table presents the indirect, direct, and total effects of the various latent variables. The results revealed that MHL had a significant positive correlation with SE ( r = 0.143, p < 0.01) and a significant negative correlation with AD ( r = −0.216, p < 0.01). However, the direct impact of MHL on FF was statistically nonsignificant ( r = −0.023, p > 0.01). FF had a significant positive effect on SE ( r = 0.262, p < 0.01) and a negative effect on AD ( r = −0.217, p < 0.01). SE also had a negative effect on AD ( r = −0.222, p < 0.01). According to the analysis conducted with the latent variables, the indirect effect of MHL on AD was −0.032 through the chain mediating effect of SE. Similarly, for the effect of FF, which indirectly affected AD, the coefficient was −0.058. SE fully mediated the relationship between MHL and AD, as well as the relationship between FF and AD. However, FF had no mediating effect on the relationship between MHL and AD.   A total of 1500 participants were enrolled in the survey; 1422 agreed to participate and returned questionnaires, for a response rate of 94.80%. Thirty questionnaires were excluded because of invalid or incomplete responses; thus, 1392 valid questionnaires were included in the analysis, indicating an effective rate of return of 97.89%. The demographic characteristics of the included participants are shown in Table . The responders were aged 18–44 years, with an average age of 29.63 ± 4.14 years. Most of them were Han (87.14%), were married (97.34%), and had a high school education or above (86.78%). The majority of the participants were currently employed (73.28%) and had medical insurance (75.22%). The proportions of primigravidas and multiparous women were 55.68% and 44.32%, respectively. Most of them did not attend pregnancy school (61.64%). More than half of the participants had good sleep (67.24%), and most of the participants were in good health (72.27%).   Table shows the means and standard deviations of the study variables. The mean depression score was 7.60 ± 4.40 points. A total of 31.90% (444) of the participants had depression, whereas 68.10% (948) of the participants experienced no depression. The mean MHL, FF, and SE scores were 43.71 ± 19.54, 7.16 ± 2.78 and 26.07 ± 6.56 points, respectively. There were statistically significant differences in MHL, FF and SE between the depressed and nondepressed groups, as shown in Table . Table shows the results of the correlation analyses of MHL, FF, SE and AD. AD was negatively correlated with MHL, FF and SE ( p < 0.01). MHL was positively correlated with SE ( p < 0.01) but not with FF ( p > 0.01). There was a positive correlation between FF and SE ( p < 0.01).   MHL, SE and FF were associated with AD, and we utilized an SEM to design a mediating model. According to the research hypothesis, a path analysis diagram of the whole model was established. However, the relationship between MHL and FF was not statistically significant. Therefore, we eliminated the direct route to better fit the structural model. Figure shows the final model with standardized path coefficients, which had an adequate fit (Table ). The results revealed that there were significant correlations between the observed variables and their corresponding latent variables (most of the regression weights were greater than 0.7). Table presents the indirect, direct, and total effects of the various latent variables. The results revealed that MHL had a significant positive correlation with SE ( r = 0.143, p < 0.01) and a significant negative correlation with AD ( r = −0.216, p < 0.01). However, the direct impact of MHL on FF was statistically nonsignificant ( r = −0.023, p > 0.01). FF had a significant positive effect on SE ( r = 0.262, p < 0.01) and a negative effect on AD ( r = −0.217, p < 0.01). SE also had a negative effect on AD ( r = −0.222, p < 0.01). According to the analysis conducted with the latent variables, the indirect effect of MHL on AD was −0.032 through the chain mediating effect of SE. Similarly, for the effect of FF, which indirectly affected AD, the coefficient was −0.058. SE fully mediated the relationship between MHL and AD, as well as the relationship between FF and AD. However, FF had no mediating effect on the relationship between MHL and AD.   To our knowledge, this study is the first to explore the relationships among MHL, FF, SE and AD in pregnant women. First, we developed a more comprehensive model on the basis of previous work . Second, we examined the potential mechanisms and interactions among these factors via an SEM. We found that MHL, FF and SE had a negative impact on the development of AD in pregnant women. Therefore, this study opens a new door for improving AD in pregnant women, emphasizing the role of MHL, SE, FF and other factors. We also illustrated how closely these variables relate to AD in pregnant women. In this study, the prevalence of AD was 31.90%, which is far higher than that reported in a previous study in this area (5.19%) , slightly higher than that reported in a multisite survey in China (28.4%) , and higher than that reported in a previous meta-analysis, which reported a pooled prevalence of 16.4% . However, the prevalence was lower than that reported by some studies, such as those in India and Ghana . The reasons might be differences among study populations, regions, study periods and the measurement tools adopted . What’s more, After the COVID-19 pandemic, pregnant women generally worried about whether the after-effects brought by COVID-19 would have an impact on the fetus, and thus were prone to experiencing symptoms of anxiety and depression. A review reported that the prevalence of depression increases significantly after major public health emergencies . At the same time, with the increase of social attention to the mental health of pregnant women, more pregnant women may be willing to voluntarily report their depressive symptoms, thus improving the detection rate of prenatal depression. AD is associated with a range of negative outcomes , which highlights the importance of timely identification and effective intervention for AD. Compared with MHL and SE, FF was directly negatively correlated with AD and indirectly affected AD through SE, with the largest total effects. The model revealed that pregnant women with lower FF scores were more likely to have AD, which was consistent with other studies . Good family functioning makes it easier for pregnant women to obtain help and support in material and mental aspects. When pregnant women encounter difficulties, their family members can provide a stable rehabilitation environment. Some studies have noted that good family relationships can effectively reduce the discomfort caused by pregnancy, increase the positive emotions of pregnant women, and thus reduce the occurrence of AD . Family members, as the largest source of social support for pregnant women, especially spouses, can effectively alleviate anxiety and depression in pregnant women . Therefore, during pregnancy, medical staff should encourage pregnant women to communicate with family members, guide pregnant women to actively express their physical and psychological discomfort, and make family members fully aware of the impact of family affection on the mental health of pregnant women, increasing the support that pregnant women receive from their families. In addition, greater perceived family support tends to bolster confidence and a sense of control, thereby strengthening pregnant women’s SE in coping with stressful events. This study also revealed that SE plays a mediating role in the relationship between FF and AD, indicating that FF can reduce depressive symptoms by enhancing SE. Relevant studies have shown that a healthy family with optimal functioning is supported by its members and that SE can generally be enhanced through social support . Many studies have shown a significant negative correlation between SE and AD , and the same conclusion was reached in this study. SE is an intrinsic personality trait that is associated with a high confidence level . Pregnant women with high SE can actively face stressful events in life, which is more advantageous for enhancing SE to effectively regulate emotions and prevent depressive symptoms. SE is an important predictor of emotional responses, choice behaviors and thought patterns . Therefore, based on this model, SE, as a modifiable factor, should be enhanced through effective intervention measures to create opportunities and enhance the ability of pregnant women to cope with mental health issues. SE is a key component of any educational intervention to address AD. HL is a factor that contributes to enhanced SE. MHL can increase SE in pregnant women, which can affect depression. This hypothesis was supported in our study. Specifically, there was a significant positive correlation between MHL and SE. The higher MHL was, the stronger SE was. This finding aligns with those previously reported . On the other hand, there was a significant negative correlation between SE and depressive symptoms. The higher SE was, the lower the degree of depressive symptoms, which is consistent with previous studies . In other words, MHL can influence depressive symptoms through the mediating effect of SE. In addition, this study revealed that pregnant women with adequate HL had a lower risk of depressive symptoms, which is consistent with the conclusions of previous studies . Each unit increase in the HL score was associated with a 4–5% reduction in the likelihood of developing depression , highlighting the protective effect of HL against depression. This might be because individuals with a higher level of HL can realize their own emotional problems when they experience negative emotions and actively obtain health information or receive help from medical service organizations to deal with their emotions in a positive way, which prevents the occurrence of depressive symptoms. This has also been confirmed in relevant studies; that is, HL can regulate the desire of individuals to seek help, thereby controlling the development of psychological problems . Therefore, medical staff can actively improve the HL level of pregnant women and enhance their SE through various measures to prevent prenatal depression. In our study, there was no significant relationship between MHL and FF. This finding was inconsistent with the results of other related studies . The HL and good FF scores were higher in the group without family dysfunction than in the group with family dysfunction , possibly because the support of pregnant women mainly comes from cooperation between family members, who explore solutions to related problems and support each other to develop good HL. However, in our study, FF had no significant effect on MHL. This might be because MHL reflects pregnant women’s knowledge of nutrition, safety, first aid, and medicine, which is acquired from medical professionals, while most family members have no medical background . There are few studies on MHL and FF. Therefore, we will continue to explore the relationships between MHL and FF in future studies. Moreover, in this study, individuals who self—evaluated their health as good were determined to have AD. The possible reasons for this contradictory result are as follows: Pregnant women's perception of "good sleep" and "good health" predominantly relies on subjective experiences. Their evaluation often places greater emphasis on physical sensations. This means they may overlook other critical aspects, such as the impact of sleep quality on overall well—being and the presence of latent psychological stress. As a result, their self—assessment criteria may deviate significantly from professional benchmarks. Moreover, the prevalent social concept is that pregnant women should present a positive image, which may prompt them to exaggerate their own health conditions. Strengths and Limitations Many variables associated with AD in pregnant women are being studied, including MHL, SE and FF. This is the strength of this research. In addition, for the first time, we established the relationships among these variables, which can provide a theoretical basis and intervention ideas to improve AD in pregnant women. Our study has several limitations. Firstly, a cross-sectional design and convenience sampling method were adopted in this study, which may lead to selection bias and limit the generalizability of the research results. Nevertheless, sufficient consideration was given to regional characteristics in this study. The survey sites covered the central urban area of Chongqing as well as the two wings of Southeast Chongqing and Northeast Chongqing. Moreover, the six surveyed sites chosen are the largest prenatal examination centers within their respective regions, so it still has a certain representativeness for this region. In the future, in order to make the results more applicable for promotion, more rigorous sampling methods can be adopted. Meanwhile, longitudinal studies can be designed subsequently to explore the complex relationships among various variables. Second, the accuracy of the participants’ answers may have been affected by the length of the research questionnaire items. Therefore, shorter forms of these questionnaires should be used in future research. Last but not least, the variables were mainly measured via self-report questionnaires, which may be influenced by social desirability. In future, objective data collection methods, such as physiological measurements and direct behavioral observations, can be incorporated alongside self—report questionnaires.   Many variables associated with AD in pregnant women are being studied, including MHL, SE and FF. This is the strength of this research. In addition, for the first time, we established the relationships among these variables, which can provide a theoretical basis and intervention ideas to improve AD in pregnant women. Our study has several limitations. Firstly, a cross-sectional design and convenience sampling method were adopted in this study, which may lead to selection bias and limit the generalizability of the research results. Nevertheless, sufficient consideration was given to regional characteristics in this study. The survey sites covered the central urban area of Chongqing as well as the two wings of Southeast Chongqing and Northeast Chongqing. Moreover, the six surveyed sites chosen are the largest prenatal examination centers within their respective regions, so it still has a certain representativeness for this region. In the future, in order to make the results more applicable for promotion, more rigorous sampling methods can be adopted. Meanwhile, longitudinal studies can be designed subsequently to explore the complex relationships among various variables. Second, the accuracy of the participants’ answers may have been affected by the length of the research questionnaire items. Therefore, shorter forms of these questionnaires should be used in future research. Last but not least, the variables were mainly measured via self-report questionnaires, which may be influenced by social desirability. In future, objective data collection methods, such as physiological measurements and direct behavioral observations, can be incorporated alongside self—report questionnaires.   Our study identified several factors associated with AD in pregnant women in China, clarified the multi-chain mediating role of MHL and SE in the relationship between FF and AD, and highlighted the influence of MHL and FF on AD in pregnant women. Therefore, it is necessary to pay more attention to these variables when planning educational programs. This finding also suggests that medical staff should encourage pregnant women to communicate with family members, encourage them to actively participate in the learning process of maternal and child health knowledge and skills, improve their HL levels, constantly enhance their SE, and ultimately reduce the occurrence of AD.   Supplementary Material 1.   