A cross-sectional relational design was used in this study. From May 2023 to August 2024, we looked into the women at high risk of preeclampsia before 20 weeks of pregnancy and came to obstetrical outpatient clinic affiliated Hospital of Jiangnan University in Wuxi City, Jiangsu Province, China, for antenatal care. The inclusion criteria for women were: any one high-risk factor or any two intermediate-risk factors (Yao Tang and Li, 2022). High risk factors: prior preeclampsia, chronic hypertension, pregestational diabetes mellitus, chronic renal disease, antiphospholipid syndrome, systemic lupus erythematosus, pregestational body mass index (BMI) ≥ 30 kg/m², receipt of assisted reproduction; intermediate risk factors: previous pregnancies complicated by FGR, placental abruption, stillbirth, and multiple pregnancies, age ≥ 40 years, primiparous labor. Exclusion criteria: someone with communication, hearing, and intellectual challenges who refuse to work together. Based on the parameters of previous related studies (Tuxunnjiang et al., 2022) r = 0.278, 1-β = 0.9, the sample size was calculated to be 131 pregnant women using G power 3.1 software, which was further expanded by 5% considering invalid questionnaires at the time of sample retrieval. The estimation showed that the inclusion of at least 138 pregnant women at high risk of preeclampsia fulfilled this investigation. The detailed recruitment process was shown in Figure 1.

This study was approved by the Ethics Committee of the Affiliated Hospital of Jiangnan University (LS2024302) and the informed consent of the pregnant women has been obtained. The study was conducted in accordance with the guidelines of the Declaration of Helsinki.

Before data collection, all researchers received standardized training. Using established protocols, they explained the study and obtained informed consent before conducting face-to-face interviews to ensure consistent questionnaire administration and interpretation. The data collection method was a combination of electronic medical record review and a paper questionnaire survey. Questionnaires were distributed and returned on the spot 150 questionnaires were handed out during the survey’s May to August 2024 period. Twelve of these were excluded from the analysis due to dropping out (Freiberger et al., 2022) and incomplete data (Traylor et al., 2020), leaving 138 questionnaires for final analysis.

Societal and obstetric attributes of the 138 individuals in the study population are shown in Table 1. All participants ranged in age from 18 to 43 years with a mean of (31.93 ± 5.10) years. For this pregnancy, the majority of women (68.1%) had a planned pregnancy. Table 1 displays the remaining obstetric clinical and sociodemographic features.

There were statistically significant differences in pregnancy stress among high-risk preeclampsia women, with intergenerational relations showing the strongest association (p = 0.004), followed by pregnancy intention (p = 0.007) and desired mode of delivery (p < 0.001). But age, BMI, education level, residence, employment status, monthly per capita household income, parity, and abortion experience did not differ statistically significantly (p > 0.05).

Stress, anxiety, depression, and self-management capacity scores during pregnancy took the form of 0.283 (0.133, 0.542), 38.750 (32.500, 45.000), 41.250 (33.750, 50.000), and 43.000 (35.000, 53.250). Of pregnant women at high risk for preeclampsia, our results showed that 8.7% had moderate pregnancy stress and 78.3% had mild pregnancy stress. Some pregnant women may feel depressed and anxious to some extent. In Table 2, the various distribution levels of their scores were displayed.

Table 3 reveals that pregnancy stress was positively correlated with anxiety, depression, and self-management capacity (r = 0.465, p < 0.001), (r = 0.437, p < 0.001), (r = 0.585, p < 0.001). Anxiety was positively associated with depression (r = 0.754, p < 0.001), and with self-management capacity (r = 0.422, p < 0.001). Additionally, self-management capacity and depression were positively correlated (r = 0.400, p < 0.001).

Significant variables were entered into the regression equation model after conducting univariate analysis and Pearson correlation analysis. As shown in Table 4, the desired mode of delivery, anxiety, and self-management capacity were significantly associated with pregnancy stress. Specifically, the regression coefficient for desired mode of delivery was 0.206 (SE = 0.049, t = 4.168, p < 0.001); the SAS were 0.011 (SE = 0.005, t = 2.338, p < 0.05); and the regression coefficient for the SQHMP was 0.010 (SE = 0.002, t = 4.745, p < 0.001). The results indicated all above three variables had a significant positive impact on pregnancy stress. In contrast, the regression coefficients for intergenerational relationships (B = –0.040, p = –0.385), planned pregnancies (B = –0.036, p = 0.485), and SDS (B = 0.003, p = 0.404) did not reach significance levels. The overall regression model explains 47.7% of the variance in pregnancy stress (R² = 0.477), After adjusting for the number of predictors, the model accounts for 45.3% of the variance (adjusted R² = 0.453), This indicates that nearly half of the variability in pregnancy stress can be explained by the combination of intergenerational relations, pregnancy planning, desired mode of delivery, anxiety, depression, and self-management capacity. The results of the analysis were statistically significant (R² = 0.477, F = 19.88, p < 0.001).

The findings of this study showed that 78.3% of pregnant women at high risk of preeclampsia had mild pregnancy stress and 8.7% had moderate pregnancy stress, similar to the research findings of Na et al. (2022). Unexpectedly, pregnant women with preeclampsia risk factors did not experience greater levels of pregnancy stress. This could be explained by a lack of awareness among this population about preeclampsia and its risk factors, as well as bias toward potential outcomes caused by preeclampsia (Püschl et al., 2023). Frawley et al. (2020) found that 67.5% of pregnant women were uncertain about preeclampsia before pregnancy. This made us wonder if educating this demographic about preeclampsia prevention could actually make them more stressed and depressed during pregnancy. Further intervention studies are required in the future to elucidate this.

An important element affecting the level of pregnancy stress in the pregnant women at high-risk preeclampsia is intergenerational relationships (with mother-in-law). The mother-in-law-daughter-in-law connection, a deeply embedded subject in Chinese culture, becomes more sensitive and delicate during the perinatal time (Qi et al., 2022). Pregnant women who had a subjective perception of “cohesion” on measures of intergenerational relationships with their mothers-in-law exhibited less pregnancy stress, as we found. Insufficient social support, especially insufficient interactions between generations, is a risk factor for prenatal mental health issues (Bedaso et al., 2021). In some patriarchal societies, such as India, many Middle Eastern, African and East Asian countries, women tend to live with their husbands’ families once married. So, it is inevitable that the relationship between mothers-in-law and daughters-in-law is deeply intertwined (Varghese and Roy, 2019). According to Riem et al. (2024) study, the mental health of pregnant women depends on the support provided by their husband’s parents and the quality of intergenerational relationships. Mrayan et al. (2016) said that the social support offered by traditional pregnancy notions could not always be good for new moms’ emotional health because of the tension between traditional and modern norms. Therefore, to balance family support and encourage a positive mindset concerning pregnancy and childbirth, the health care system must provide more assistance in coordinating prenatal education with the elder generation.

Another element that influences pregnant stress in those at high risk for preeclampsia is pregnancy intention. Interestingly, compared to women with unplanned pregnancies, those with planned pregnancies suffered higher levels of pregnancy stress. This finding is consistent with the results of the Rashidi et al. (2025) study. The reason for this is that, on the one hand, women with unplanned pregnancies often choose to terminate their pregnancies early in the pregnancy and are not included in the follow-up; on the other hand, women with planned pregnancies may instead suffer from greater psychological stress and anxiety due to the pursuit of the idealized expectation of becoming a “perfect mother.” Contrary to what we found, the Maxson and Miranda (2011) study found that women who had unplanned or untimely pregnancies had higher levels of depression, anxiety, and perceived stress. This may reflect that we included women with assisted reproductive pregnancies in our high-risk group for preeclampsia. Pregnancy stress was reported to be significantly higher in women who had received assisted reproduction than in those who had been naturally conceived. The major causes of this stress include worries about how the pregnancy would turn out, the mental and physical strain of the medical procedure, and the pressure from society (Öztürk et al., 2021). This was also confirmed by a cross-sectional survey of pregnancy stress between naturally conceived women and women who underwent assisted reproduction techniques, conducted by our scholar Xuehua Cao et al. (2011). Therefore, the inclusion of this population had the potential to confound the results. The further studies should be more cautious about investigating women undergoing assisted reproduction.

A particular factor that influences pregnancy stress in those at high risk for preeclampsia was the desired mode of delivery. Our research findings, similar to those reported by Luyan Liu (2009), demonstrated that pregnant women who wished for a caesarean section experienced higher levels of pregnancy stress compared to those who expected natural childbirth. A study by Xihong Zhou (2011) found that prenatal anxiety affected a woman’s choice of delivery method. Concern regarding the fetus and fear of labor pains have made psychological issues the primary cause of the rise in undiagnosed cesarean procedures. To lessen mothers’ negative feelings and lower the rate of cesarean sections, obstetricians should educate them about scientific health care and offer them comprehensive psychosocial assistance.

Depression and anxiety were highly co-morbid during pregnancy, as evidenced by our study of high-risk preeclampsia patients. In a similar vein, Lee et al. (2021) confirmed a persistent association between anxiety and depression on women during pregnancy. A substantial number of studies have indicated that adverse emotional states during pregnancy can alter the immune system and physiology of the mother, such as vasoconstriction of the placenta and other small veins and arteries throughout the body, progressively leading to an increase in blood pressure and peripheral resistance (Traylor et al., 2020). According to the past study, women who experienced more distress in their first trimester were more likely to develop preeclampsia in their second trimester (Giurgescu et al., 2015; Kurki et al., 2000). Notably, a survey conducted by Dan Li et al. (2013) across pregnant women observed that unfavorable psychological states frequently resulted in inflated perceptions and emotions regarding life events, which might raise pregnancy stress levels. As a result, it is imperative that medical professionals examine pregnant patients at risk of preeclampsia for mental health issues and offer extra effective psychological support in order to relieve pregnancy stress.

Our research showed that self-management capacity had a positive correlation with pregnancy stress experienced. This finding suggested that moderate pregnancy stress motivated self-management behaviors to some extent, or that pregnant women with high self-management capacity were more inclined to perceive and report pregnancy stress. In a cross-sectional study of 440 pregnant women during the 2019 novel coronavirus (COVID-19) pandemic, maternal self-care was associated with COVID-19 disease perceived severity was positively associated. This result is similar to our findings, suggesting that pregnant women with high self-care are more able to perceive and report associated stressors and threats (Khazaeian et al., 2022). Similarly, another study on the similar relationship between general self-efficacy and pregnancy stress in women with preterm labor also indicated that high levels of self-efficacy may amplify pregnancy stress (Cho and Kim, 2024). However, the specific causal relationship between pregnancy stress and self-management ability needs to be explored in future prospective intervention studies. We also focused on pregnant women at high risk of preeclampsia but do not experience pregnancy stress, who appeared to lack the ability to manage their pregnancies. Interestingly, a lower incidence of preeclampsia was observed in pregnant women with enhanced self-management capacity, as evidenced by the findings of the Alnuaimi et al. (2020) study.

Given that psychosocial stress, including that associated with pregnancy, anxiety, depression, and self-management capacity, is to some extent an external factor, it can often be mitigated through appropriate interventions (Vollebregt et al., 2008). It is essential to gain insight into the correlation between adverse emotional states, such as those related to pregnancy, especially related to high-risk pregnancies with preeclampsia, and self-management capacity. And for those at high risk for preeclampsia, it ought to be that future clinical practice incorporate a quick evaluation of pregnancy stress in early prenatal care. Furthermore, pregnant women with high risk of preeclampsia but without pregnancy stress should also pay extra attention to self-management. Proactive prenatal care can help alleviate adverse pregnancy emotions and reduce stress in pregnant women at high risk of preeclampsia, thereby lowering their probability of developing preeclampsia and achieving satisfactory pregnancy outcomes.