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El Kahwaji et al. BMC Psychology (2025) 13:91 
https://doi.org/10.1186/s40359-025-02410-y
BMC Psychology
*Correspondence:
Souheil Hallit
souheilhallit@usek.edu.lb
Full list of author information is available at the end of the article
Abstract
Background Cultural variations in pregnancy and childbirth experiences can influence the causes and contributing 
factors of postpartum depression (PPD). However, research on this issue remains scarce in Arab countries, especially 
in Lebanon. This study aimed to assess the prevalence of PPD and explore socio-contextual factors affecting it in 
Lebanon during the COVID-19 pandemic. It also sought to validate the psychometric reliability of the Arabic version 
of the Edinburgh Postnatal Depression Scale (EPDS) among Lebanese women.
Methods A cross-sectional study was conducted between May 2022 and July 2022, with 402 Lebanese adult 
postpartum women (mean age 31.46 ± 4.88 years) enrolled from the maternity ward at CHU-Notre Dame des Secours 
Hospital in Byblos, Lebanon by responding to an online survey after obtaining informed concent. Along with the 
EPDS, the following measures were administered to participants: The Multidimensional Scale of Perceived Social 
Support, the Fear of COVID-19 Scale, and the Lebanese Anxiety Scale-10.
Results Our findings demonstrated appropriate psychometric properties of the Arabic one-factor, 10-item EPDS in 
our sample of Lebanese women. The scale yielded good composite reliability (ω = 0.97), and appropriate patterns of 
correlations with anxiety and social support measures, thus attesting for its convergent validity. A total of 239 women 
(59.5%) had potential postpartum depression. Multivariate analysis showed that perceived childbirth experience (as 
“normal” (Beta= -2.57), “good” (Beta= -3.45) and “very good” (Beta= -4.14)), with worries that the newborn will get hurt/
die during labor (“rarely” (Beta = 1.43) and “never” (Beta = 1.24)), a lower financial burden (Beta = − 0.19) and a higher 
social support (Beta = − 0.02) were significantly associated with lower rates of PPD; while higher levels of anxiety 
(Beta = 0.32) were associated with increased symptoms of PPD.
Conclusion The study highlights the significant burden of PPD among Lebanese women, with an alarmingly high 
prevalence. Key factors associated with PPD—such as anxiety, childbirth experience, and social support—are largely 
Prevalence, correlates of postpartum 
depression during the COVID-19 pandemic; 
and validation of the arabic edinburgh 
postnatal depression scale among Lebanese 
women
Christian El Kahwaji1, Elie Barakat1,2, Feten Fekih-Romdhane3,4, Camille Akkari1, Savio Barakat1,2 and Souheil Hallit1,5,6*
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Page 2 of 14El Kahwaji et al. BMC Psychology (2025) 13:91 
Background
Pregnancy and childbirth can prompt a myriad of emo-
tional changes, which may, in turn, trigger psychiatric ill-
nesses including postpartum depression (PPD) [1]. PPD 
is a disabling but treatable [2] psychiatric illness, consid-
ered the most common childbearing complication. Most 
of the previous research on PPD has been performed in 
Western countries [3] with a prevalence estimated at 10% 
[4]. A significant decline in the prevalence of PPD has 
been noticed among 13 states in the USA between 2004 
and 2012 [5]. Nonetheless, disparities remain around the 
world, as statistics for middle to low-income countries 
showcase a prevalence ranging between 20 and 60% [3]. 
The Diagnostic and Statistical Manual of Mental Dis-
orders, 5th edition (DSM-5) defines it as a major depres-
sive event with peripartum onset, thus occurring during 
pregnancy until 4 weeks postpartum [6]. PPD symp-
toms range from changes in appetite and sleep patterns, 
fatigue, psychomotor retardation, lack of energy, feelings 
of worthlessness/guilt, to suicidal ideations [6]. The PPD 
diagnosis might be challenging, particularly because of 
symptoms related to exhaustion, sleep and culinary dis-
turbances, which are often encountered in the postpar-
tum context [7]. However, according to Beck, PPD “isn’t 
just the blues”; but a serious crippling mood disorder and 
a “thief that steals motherhood” [8]. Despite its multiple 
deleterious effects on the mother-baby relationship [9], 
PPD has long gone unnoticed and untreated by health-
care professionals, leaving mothers to endure confusion 
and distress in silence [10]. 
The exact pathophysiology of PPD is still unknown. 
A rapid postpartum decline in female hormones could 
probably increase the risk of developing the disease in 
vulnerable women [2]. The effect of hormones, such as 
estrogen, on the neural pathways implicated in emo-
tion and mental illnesses such as depression, remains a 
controversial issue [11]. According to Stewart et al., the 
strongest risk factors for PPD are an underlying psychi-
atric pathology like depression and anxiety, in addition 
to the occurrence of stressful events, such as relation-
ship instability and poor social or familial support [12]. 
Obstetrical complications, lower socioeconomic status 
or being a single mother were considered predictors of 
minor significance [13]. Other studies focused on fear 
of childbirth and depressive traits which were tightly 
associated with bad birth experiences due to deficient 
pain management protocols and lack of overall support 
and care during the perinatal period [14, 15]. In addi-
tion to these risk factors, research has also pointed to 
the substantial impact of the pandemic on postpartum 
women’s mental health. According to Lebel et al., the 
COVID-19 pandemic presented severe mental challenges 
for pregnant women both on the short run, by exacer-
bating PPD due to stressful, serious, and lethal illnesses 
[16], and on the long run, impacting the normal develop-
ment of the baby [17]. Survivors of the SARS epidemic 
in 2003 manifested greater rates of psychiatric conditions 
[18]. A cohort study conducted in 2020, aiming to assess 
intellectual function in women that gave birth during the 
COVID-19 outbreak compared to those before the pan-
demic, showed that this global event was independently 
linked to a significant decline in “subjective” maternal 
cognitive abilities immediately in the puerperal period 
[19]. 
To date, there is a noticeable lack of evidence-based 
knowledge revolving around PPD, its prevalence and 
associated risk factors taking into consideration the 
socio-cultural and demographic variations globally, 
especially in the Arab as well as in developing countries. 
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	Prevalence, correlates of postpartum depression during the COVID-19 pandemic; and validation of the arabic edinburgh postnatal depression scale among Lebanese women
	Abstract
	Background
	Methods
	Study design
	Participants
	Ethical approval
	Minimal sample size calculation
	Demographics
	Measures and instruments
	Analytic strategy
	Factoranalysis
	Further analyses
	Results
	Exploratory factor analysis
	Confirmatory Factor Analysis of the EPDS scale
	Composite reliability
	Divergent validity
	Bivariate analysis
	Multivariable analysis
	Discussion
	Rate of postpartum depressive symptoms
	Correlates of postpartum depression
	Clinical implication
	Study limitations
	Conclusion
	Referencescountries, even though PPD 
is likely to affect at least 1 in 5 mothers [20]. There are 
substantial culture-specific differences surrounding the 
pregnancy and childbirth experience; that might influ-
ence the causal factors, nature, manifestation, and cor-
relates of PPD. For example, women in Arab countries 
are under family pressure to have children immediately 
after marriage [21], and live in a society where male 
newborns are preferred over females [22], which may 
result in the birth of many unwanted children. Previous 
studies also found that Arab women reported a lack of 
knowledge about pregnancy and childcare [22], feeling 
unhappy with and lacking control over their childbirth 
experience [23]. On the other hand, a 40-day period of 
support is provided to postpartum women by mothers 
and other female relatives after childbirth [24]; and this 
family centered care has been shown to contribute to 
reducing distress and enhancing self-confidence during 
the motherhood experience [25]. In a study conducted in 
Bangladesh, 34% of mothers experienced PPD within the 
first six months after birth, while 58.6% reported a his-
tory of domestic violence (DV), including physical, emo-
tional and controlling behaviors which were significantly 
linked to higher PPD risk [26]. Among 39 immigrant 
Afghani women interviewed four months after labor, 
41% reported feeling depressed or very unhappy since 
the birth, and 31% scored as likely to be depressed on the 
preventable and modifiable. Nonetheless, there is an imperative need for future longitudinal and qualitative research, 
to better understand obstetrical experiences, address PPD and confirm causality of the associations found.
Keywords Pregnancy challenges, Postpartum depression, COVID-19 pandemic, Economic crisis, Lebanon
Page 3 of 14El Kahwaji et al. BMC Psychology (2025) 13:91 
Edinburgh Postnatal Depression Scale (EPDS). Common 
factors contributing to emotional distress included iso-
lation, lack of support, and feeling overwhelmed by life 
events [27]. In the Lebanese context specifically, the prev-
alence of PPD was estimated around 21.3% in a sample of 
396 Lebanese women in a study by Chaaya et al. [28]. The 
same study identified lack of social reinforcement, ante-
natal depression, low educational level, chronic comor-
bidities and joblessness as main factors associated with 
PPD [28]. According to Hobeika et al., 34.8% of Lebanese 
mothers had a positive screening for PPD [29]. Leba-
nese healthcare focuses mostly on the pre-partum phase, 
including obstetrical issues and the baby’s wellbeing, 
rather than the postpartum period [30]. There are hardly 
any standardized medical follow-ups or home services 
after hospital discharge. Postpartum care is restricted to 
just a single obstetrical consultation 6 weeks after deliv-
ery, that is only accomplished by half of the Lebanese 
women [30, 31]. Besides, mental health remains widely 
seen as a shameful topic in many communities including 
the Lebanese. Women may feel uneasy or deranged talk-
ing about their thoughts and feelings and may be even 
discouraged to seek professional help, out of fear of judg-
ment, as it is perceived against social and cultural stan-
dards and expectations [9, 32]. Finally, the COVID-19 
outbreak worsened the already fragile economic situation 
and challenging mental health issues among postpartum 
women. The pandemic occurred with an unprecedented 
economic hardship since October 2019, and the Leba-
nese pound has lost nearly 85% of its value. Many Leba-
nese have lost their jobs or seen their businesses slow 
down. A large proportion of the adult population looked 
to emigrate; however, they found themselves obliged to 
live a hazardous life of economic instability because most 
can’t settle outside the country [33]. Moreover, the coun-
try’s state reached its worst peak following the Beirut’s 
port explosion on August 4, 2020; the devastating blast 
resulted in at least 180 deaths, 6,000 injured, and around 
300,000 homeless individual [34]. The prevalence of psy-
chiatric disorders has escalated ever since. This “triple-
hit” makes the general Lebanese population more likely 
to be affected psychologically. Before the actual crisis, a 
cross-sectional study showed that about one third of the 
Lebanese adult population were in mental distress [35]. 
In addition, fear of the pandemic [36] along with the fear 
of poverty [37] may both trigger psychological distress 
and favor the exacerbation of mental illnesses.
In this study, we aimed to provide a clearer insight and 
deeper understanding of prevalence rates and potential 
socio-contextual confounding factors of PPD in Lebanon 
during the COVID-19 pandemic. This should provide us 
with an in-depth understanding and formulation of the 
scope of the problem, especially in the Lebanese case, 
which offers an appropriate context for investigating 
women’s mental state in the puerperal period in the con-
text of COVID-19. As a secondary objective, we sought 
to confirm the psychometric properties of the Arabic 
EPDS in our sample of Lebanese women prior to its use.
Methods
Study design
We conducted a cross-sectional study between May and 
July 2022. The survey was distributed to postpartum 
women from the maternity ward at CHU-Notre Dame 
des Secours Hospital in Byblos, accessed via a QR code 
redirecting the participant to the Google Form link. The 
study was furthermore advertised on social network-
ing platforms and included an approximate duration of 
10–15  min. Once accessed, participants were presented 
with a digital consent form that familiarizes them with 
the topic, ensuring freedom of contribution to the study, 
free of coercion, undue influence, or duress. In fact, this 
form emphasizes that participants will not receive any 
financial compensation and can refuse to be involved or 
stop at any time, for any reason with no adverse conse-
quences or penalty. Moreover, participants were pro-
vided with a reference contact information in case they 
required any clarification or had any pertinent research 
question that might have helped them fill the question-
naire more efficiently.
Inclusion criteria for participation were being a female 
adult resident and citizen of Lebanon, aged between 18 
and 51 years old, that got pregnant by natural or artificial 
means. They can be of any socio-economic status, of any 
educational level, whether working or not at the moment 
of the study. All hospital-based delivery methods (vagi-
nal, C-section), regardless the gender of the baby, nor the 
parity or the gender of previous siblings were included.
Excluded were those who had any previously diagnosed 
mental illness, those who refused to fill out the ques-
tionnaire or any woman who had undergone a stillbirth, 
which is the loss of the baby at or after 20 weeks of preg-
nancy [38] that could occur any time during pregnancy 
whether before or per partum [39, 40]. Women who 
had postnatal complications or near-death experience, 
incomplete forms or women who gave birth in an ambu-
lance or at home were also excluded.
Internet protocol (IP) addresses were examined to 
ensure that no participant took the survey more than 
once. After providing digital informed consent, partici-
pants were asked to complete the instruments described 
below, which were presented in a pre-randomized order 
to control for order effects.
Participants
A total of 402 participants were enrolled in this study, 
with a mean age of 31.46 ± 4.88 years. All were married. 
Page 4 of 14El Kahwaji et al. BMC Psychology (2025) 13:91 
Other descriptive statistics of the sample can be found in 
Table 1.
Ethical approval
After careful review of the study proposal in its meeting 
held on February 22, 2022, ethics committee approval 
was obtained from the CHU-Notre Dame des Secours 
Institutional Review Board (CR: 1/2022). A written 
informed consent was assumed obtained upon submis-
sion of the online form.
Minimalsample size calculation
We used G*Power software to compute the minimal 
sample size required for our analysis. Considering an 
alpha error of 5%, a power of 95%, using a minimum R2 
of 10%, allowing a total number of predictors up to 20, 
the minimal sample size required was 293 participants. 
Nonetheless, a larger sample was collected during the 
course of this research project, consisting of 402 par-
ticipants. This sample would strengthen the validation of 
the psychometric robustness of the Arabic version of the 
EPDS within our cohort of Lebanese women prior to its 
implementation.
Demographics
Participants were asked to provide their demographic 
details consisting of age, place of residence, number of 
children, gender of the newborn, religion, marital sta-
tus, highest educational attainment, professional status, 
health coverage, and the Household Crowding Index 
(HCI); the latter reflecting the socioeconomic status of 
the family. It is the ratio of the number of persons liv-
ing in the house over the number of rooms in it (exclud-
ing the kitchen and the bathrooms) [41]. Respondents 
were also asked to grade their financial burden during 
the Lebanese economic crisis by answering the question 
“How much pressure do you feel concerning your actual 
financial situation overall?” on a scale from 1 to 10, with 
10 being referred to as unbearable pressure.
Measures and instruments
The questionnaire was constructed in Arabic, as it is the 
native language of Lebanon, in which enrolled women 
were given full information about the study starting by 
reassurance that the answers given will be kept private, 
anonymous, confidential, stored securely, and would be 
used only for medical research purposes.
After completion of the first part of the questionnaire 
consisting mainly of sociodemographic characteristics, 
participants were presented with the second part which 
dives further into obstetrical issues, starting with several 
dichotomous questions about pregnancy whether it was 
“planned” or “happened unexpectedly”, whether it was 
“natural” or the couple “resorted to artificial methods”, 
whether the participant have ever suffered from a sponta-
neous miscarriage or because of chromosomal/morpho-
logical fetal abnormalities and whether the last delivery 
method was a “natural vaginal delivery” or a “C-section”.
Furthermore, respondents were asked about potential 
complications encountered during pregnancy, whether 
they suffered from high blood pressure, high blood sugar 
levels, infections, pre-eclampsia, preterm labor, fetal dis-
tress, persistent nausea and vomiting or iron-deficiency 
anemia to which they responded by “yes” or “no”.
A four-point Likert-type scale was used to evalu-
ate mothers’ perceptions of their childbirth experience, 
ranging from 1 (“very bad experience”) to 4 (“very good 
experience”). To assess their feelings during childbirth, 
mothers selected from the following options: “very 
frightened/tense,” “panicked/desperate,” “weak/alone,” 
“very natural,” or “I felt safe and confident in myself.” 
Additionally, participants were asked about their con-
cerns regarding the baby’s safety during labor. They rated 
the frequency of thoughts about the baby possibly being 
hurt or dying on a scale ranging from 0 (“never”) to 3 
(“always”). Lastly, mothers provided a self-assessment of 
their pain during childbirth using a scale from 1 to 10, 
where 10 indicated unbearable pain.
The Multidimensional Scale of Perceived Social 
Support (MDSPSS), which is a.
short and commonly used self-report instrument for 
estimation of social support within the society, based 
on three explicit sources of emotional support: “family, 
friends and the significant other” [42]. This scale includes 
a total of 12 items subdivided into 3 subscales of 4 items 
each; each subscale refers to one of the three distinct 
sources of emotional support. Each item is scored based 
on a 7-point rating scale ranging from: 1= “strongly dis-
agree” to 7= “strongly agree” [42]. Higher scores manifest 
greater feelings of social support [43]. We used the vali-
dated and Arabic translated version of the scale [43]. 
Table 1 Sociodemographic and other characteristics of the 
sample (N = 402)
Variable N (%)
Education level
Secondary or less 85 (21.1%)
University 317 (78.9%)
Employment
No 174 (43.3%)
Yes 228 (56.7%)
Mean ± SD
Age (years) 31.46 ± 4.88
Duration of marriage 5.31 ± 4.05
Number of children 1.89 ± 1.00
Household crowing index (person/room) 1.17 ± 0.52
Financial burden 8.08 ± 1.89
Page 5 of 14El Kahwaji et al. BMC Psychology (2025) 13:91 
The Fear of COVID-19 Scale (FCV-19 S), which is a 
tool developed in 2020, after the.
emergence of COVID-19 in India by Ahorsu et al. [44]. 
It is a 7-item scale in which each respondent manifests 
their degree of agreement with each statement based 
on a 5-point Likert scale, ranging from 1= “strongly dis-
agree” to 5= “strongly agree” [45]. The greater the score, 
the higher the estimated fear of COVID-19 [44]. We used 
the validated and Arabic translated version of the scale 
[46]. 
The Lebanese Anxiety Scale-10 (LAS-10), which is 
a tool of 10 items, designed to evaluate anxiety in both 
adults [47] and adolescents [48]. Items 1–7 were scored 
in analogy to the visual analogue scale used in pain esti-
mation (from 0 to 10) ranging from 0–1= “not present” 
to 8–10= “very severe”. Nonetheless, statements 8–10 
were rated on the basis of a 4-point Likert scale that take 
into account the number of times symptoms manifested 
ranging from “almost never” to “almost always”. The total 
score is computed by adding all answers, with higher 
scores referring to greater anxiety levels [47]. 
The Edinburgh Postnatal Depression Scale (EPDS), 
which is a 10-item screening.
tool for detection and evaluation of the severity of 
possible postpartum depression, developed by Cox et 
al. in 1986 [49]. The mother is asked to choose the most 
appropriate response that illustrates best how she felt in 
the last 7 days [49]. The total score ranges from 0 to 30, 
with a probable depression considered for a score of 10 
or greater [29]. We used the Arabic version of the scale, 
which validity has been further examined by Ghubash 
et al. (1997) [50] and considered as a “reliable screening 
tool” for PPD as early as 30 to 40 days after labor, in a 
study conducted on a sample of Lebanese women [51]. 
Analytic strategy
Factor analysis
There were no missing responses in the dataset. An 
exploratory-to-confirmatory factor analysis (EFA-CFA) 
was followed to determine the factor structure of the 
Edinburgh postpartum depression scale. For this purpose, 
the total sample was randomly divided into two groups 
using the SPSS cases selection option. The first sample 
was used for the EFA, whilst the second one was used 
for the CFA. The EFA was initiated to confirm the legit-
imacy of the construct of the EPDS in our sample. The 
principal component analysis was used as the method for 
component extraction; the Pearson correlation matrix 
was used during the analysis. The parallel analysis was 
used to determine the number of dimensions, with the 
normalized promax used as a rotation to achieve factor 
simplicity. The Kaiser–Meyer–Olkin (KMO) value and 
the Bartlett’s sphericity test were checked for sampling 
adequacy. The factors with Eigen values > 1 were kept. A 
Weighted Root Mean Square Residual (WRMR)using the maxi-
mum likelihood method and fit indices.
Further analyses
Composite reliability in both subsamples was assessed 
using McDonald’s ω, with values greater than 0.70 reflect-
ing adequate composite reliability [54]. McDonald’s ω 
was selected as a measure of composite reliability because 
of known problems with the use of Cronbach’s α [55]. To 
assess divergent validity, we examined bivariate correla-
tions between EPDS and other variables such as anxiety 
and social support. Based on Cohen [56], values ≤ 0.10 
were considered weak, ~ 0.30 were considered moder-
ate, and ~ 0.50 were considered strong correlations. The 
PPD score had a normal distribution as its skewness and 
kurtosis values varied between − 1 and + 1 [57]. The Stu-
dent t and ANOVA tests were used to compare two and 
three or means respectively. Bonferroni correction was 
applied by dividing the p value of 0.05 by the total num-
ber of variables entered in the analysis (= 28); therefore, 
significance in the bivariate analysis was estimated at 
p =.05/28 = 0.002. Pearson test was used to correlate two 
scores (i.e., depression and pain/age). A linear regres-
sion, taking the PPD score as the dependent variable was 
conducted. All variables that showed significance in the 
bivariate analysis were taken as independent ones in the 
final mode. Significance was estimated at pof social support and greater anxi-
ety remained significantly associated with PPD. Variables 
such as fear of COVID-19, having contracted an infection 
or having constant nausea and vomiting during preg-
nancy, experiencing preterm labor, or having previous 
miscarriages were not remarkable predictors in our mul-
tivariate analysis, although they were noteworthy in the 
bivariate analysis.
Rate of postpartum depressive symptoms
One of the main findings of this study was that 59.5% of 
women in our sample had potential PPD. This indicates 
a significant increase, in comparison to the only similar 
study conducted by Chaaya et al. back in 2002, showing 
an overall prevalence of 21% for PPD [28], a finding that 
was deemed congruent with other studies in the Middle 
Eastern area 20 years back [50]. Using the EPDS scale 
scoring principles in a sample of 228 Lebanese women, 
El-Hachem et al. (2014), stated that around 33.3% of 
women on day 2 of their postpartum had depressive 
symptoms vs. 12.8%, for those in their 30–40 days post-
partum [51]. In their systematic review about PPD in the 
Arab world, Ayoub et al. (2020) found disparities regard-
ing prevalence of PPD even between different countries 
in the region, due to the variety of instruments, cut-off 
points and timeframe of assessment [20]. In fact, 15–25% 
of women had a “confirmed” or “likely” PPD, as con-
cluded by 12 different studies. Taking into account an 
EPDS cutoff score greater or equal to 10, indicative of 
potential PPD, studies in regional Arab countries show-
cased a rate ranging from 13.2% in Tunisia (6 weeks after 
labor) [58]. In Kom Ombo (Egypt), the rate of PPD was 
estimated at around 73.7%; it is important to mention 
that a small sample size of 57 participants and a consider-
ably broad interval of time (2 weeks up to a year postpar-
tum) were considered [59]. Other studies, setting a cutoff 
score at greater or equal to 12 [20], resulted in rates of 
postpartum depressive symptoms ranging from 9.2% in 
Sudan [60], 17.6% in Qatar [61], 20.1% in Morocco [62] 
up to 37.1% in Bahrain [63]. The significant discrepancy 
of our results compared to other neighboring Arab coun-
tries could be related to some over-estimation by con-
sidering the original cutoff of “10 or greater” score that 
would result in higher sensitivity with a slight decrease in 
specificity [50] on the first hand, and due to the undeni-
able aggravating traumatic load on the Lebanese popula-
tion [64], after the devastating Beirut port explosion in 
2020 alongside the COVID-19 rising cases [65] and the 
heavy economic burden caused by the unprecedent infla-
tion rise in over 30 years on the other hand [66]. 
Correlates of postpartum depression
In our study, a “normal” to “very good” perceived child-
birth experience were found to be associated with less 
PPD compared to a “very bad” estimation. This is in 
line with previous findings. For instance, an Italian 
Table 4 Correlation of the postpartum depression score with other continuous variables
1 2 3 4 5 6 7 8 9 10
1. Postpartum depression 1
2. Age 0.01 1
3. Duration of marriage 0.09 0.64*** 1
4. Total number of children 0.05 0.46*** 0.72*** 1
5. Household crowding index 0.25*** 0.13* 0.39*** 0.47*** 1
6. Financial burden 0.20*** − 0.02 0.15** 0.08 0.36*** 1
7. Social support − 0.37*** 0.01 − 0.16** − 0.12* − 0.36*** − 0.22*** 1
8. Fear of COVID-19 0.34*** 0.08 0.12* 0.07 0.22*** 0.27*** − 0.21*** 1
9. Anxiety 0.70*** − 0.03 0.08 0.02 0.26*** 0.27*** − 0.34*** 0.37*** 1
10. Pain during childbirth 0.38*** − 0.03 0.08 − 0.03 0.27*** 0.21*** − 0.23*** 0.32*** 0.36*** 1
*pvs. never*) 1.43 0.15SH carried out the analysis and interpreted the results; 
FFR reviewed the paper for intellectual content; all authors reviewed the final 
manuscript and gave their consent.
Funding
None.
Data availability
All data generated or analyzed during this study are not publicly available 
due the restrictions from the ethics committee. Reasonable requests can be 
addressed to the corresponding author.
Declarations
Ethics approval and consent to participate
Ethics approval for this study was obtained from the CHU-Notre Dame des 
Secours Institutional Review Board after careful review of the study proposal 
on February 22, 2022. (CR: 1/2022). A digital informed consent was obtained 
from all subjects and/or their legal guardians for study participation and was 
considered equivalent to receiving a written informed consent. All methods 
were performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, 
P.O. Box 446, Jounieh, Lebanon
2Obstetrics and Gynecology department at Notre Dame des Secours, 
Centre Hospitalier Universitaire, Street 93, Postal Code 3, Byblos, Lebanon
3The Tunisian Center of Early Intervention in Psychosis, Department of 
Psychiatry “Ibn Omrane”, Razi Hospital, Manouba 2010, Tunisia
4Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
5Department of Psychology, College of Humanities, Effat University, 
Jeddah 21478, Saudi Arabia
6Applied Science Research Center, Applied Science Private University, 
Amman, Jordan
Received: 5 March 2024 / Accepted: 20 January 2025
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