Introduction
Pregnancy is one of the most stressful events in women’s lives, which exposes them to psychological disorders [1، 2]. Depression is the most common psychological disorder during pregnancy [3]. Depression is a set of mental disorders that are associated with loss of interest or pleasure in normal experiences, low mood, and cognitive, behavioral, physical and emotional symptoms [4]. The probability of depression in women is higher than in men due to biological factors such as changes in the level of ovarian hormones [2]. The global prevalence of depression during pregnancy is about 20.7% [5], while it has a high prevalence of about 41.22% in Iran [6]. Factors causing the occurrence of depression in pregnant women include disputes and arguments in married life, unfortunate events in life, living in a large family, low income of spouse, young age, previous history of mental disorders, lack of social support, adverse pregnancy complications, and unwanted pregnancy [7]. Depression is a disorder that harms women and often remains untreated [8]. Maternal depression affects the health and development of the baby and has long-term consequences for the mental health of future generations [9]. Depression during pregnancy causes adverse consequences such as miscarriage, low birth weight, premature birth, pre-eclampsia, cesarean section, hospitalization of the baby in the neonatal intensive care unit, and breastfeeding problems. Postpartum depression increases the risk of maternal suicide [10].
One of the protective psychological factors against depression is self-compassion [12]. In 2003, Neff defined self-compassion as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness. Self-compassion also involves offering non-judgmental understanding to one’s pain, inadequacies and failures, so that one’s experience is seen as part of the larger human experience”. Self-compassion thus includes three main components: 1) Being kind to oneself instead of blaming oneself when facing failure, 2) Accepting pain and suffering as an integral part of the shared human experience, and 3|) Having mindfulness and a balanced approach to negative thoughts and feelings [11]. Self-compassion turns negative feelings caused by pains and failures into feelings of kindness towards oneself; thus, it can be said that self-compassion promotes mental health and self-esteem of a person [12]. Self-compassion helps a person to cope with life’s problems and events and makes it easy to bear difficulties and problems [13]. Self-compassion regulates moods and emotions in depressed people [14]. The presence of self-compassion in a person is a protective factor against depression during pregnancy [15]. Self-compassion can also reduce stress and anxiety [16، 17].
Considering the high prevalence of depression during pregnancy and its adverse effects on the health of the family and children, it may be beneficial to find a relationship between some psychological factors and depression during pregnancy [3، 10]. In addition, since all population policies in Iran are currently based on promoting childbearing and having young population, it is expected that the adoption of effective strategies to empower pregnant mothers in self-compassion can lead to the promotion of their mental health and self-care, and thus cause an increase in the fertility rate. On the other hand, since there are limited studies for the relationship between self-compassion and depression in pregnant women, the present study aims to determine the relationship between self-compassion and depression in pregnant women in Kermanshah, Iran.

Materials and Methods
This is a cross-sectional study that was conducted in 2023. The study population consisted of all pregnant women who visited comprehensive urban health centers in Kermanshah. The inclusion criteria were pregnancy, age 20-35 years, having depressive symptoms according to DSM 5 criteria and an Edinburgh postnatal depression scale (EDPS) score above 12, no history of any known mental disorders, and not experiencing traumatic events in the past year. The exclusion criteria were unwillingness to continue participating in the study and not fully answering the questions in the questionnaire. Sampling was done in a multi-stage cluster random sampling method. First, comprehensive urban health service centers were considered as clusters. Then, within each cluster, a number of comprehensive health service centers were selected randomly with the lottery method. From each center, the list of pregnant women was extracted using the SIB system and then the samples were randomly selected from the list. The sample size was calculated based on the results of Khorramnia et al.’s study [18] using the Equation 1. In this regard, the minimum sample size was estimated to be 479. By considering a 10% sample drop, the sample size increased to 527.




Data collection tools included a demographic/obstetric form, the EDPS, and the self-compassion scale (SCS). The EDPS was designed by Cox in 1987. It has 10 items rated on a 4-point Likert scale from not at all to always. A total score above 12 indicates a postpartum depression. Based on Cox’s study, Cronbach’s α for the EDPS is 0.87 [19]. For the Persian version of the EDPS, Galini Moghaddam et al. reported a Cronbach’s α of 0.70 [20]. The SCS was designed by Neff et al. in 2003 [12]. It has 26 items and six subscales of self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification. The items are scored on a 5-point Likert scale from 1 (completely disagree) to 5 (completely agree). Items 1, 2, 4, 6, 8, 11, 13, 16, 18, 20, 21, 24 and 25 have reversed scoring. In Neff et al.’s study, the reliability for the subscale of self-kindness was reported 0.88; for self-judgment, 0.88; for common humanity, 0.80; for isolation, 0.85; for mindfulness, 0.85; and for over-identification, 0.88 [12]. In Khosravi et al.’s study for the Persian SCS, Cronbach’s α for the overall scale was reported as 0.76. For the subscales of self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification, Cronbach’s α was reported as 0.81, 0.79, 0.84, 0.85, 0.80, and 0.83, respectively [21].
After obtaining permission from the university and an informed consent from the participants and explaining the study objectives to them, the questionnaires were completed by the participants. The collected data were analyzed in SPSS software, version 26. Spearman’s correlation test was used to determine the relationship between depression and self-compassion. Based on cutoff point of 12 for the EDPS, logistic regression analysis was used to determine the self-compassion components that could predict depression in pregnant women. The significance level was set at 0.05.

Results
In this study, 527 pregnant women participated. The mean age was 27.8±4.7 years, ranged 20-35 years. The mean gestational age was 24.9±8.5 weeks, ranged 9-41 weeks. According to the findings, 63.3% (n=365) had depression. The mean scores of EDPS and SCS are presented in Table 1.



According to the results of Spearman’s correlation test in Table 2, there was a negative and significant association between self-compassion and depression in pregnant women (r=-0.153, P<0.05).



According to the results of logistic regression analysis in Table 3, the components of self-kindness, common humanity and had a role in predicting depression in pregnant women.



Discussion
In the present study, the relationship between self-compassion and depression in pregnant women was investigated. The results showed a significant association between them. Fourianalistyawati et al. conducted a study for determining the role of mindfulness and self-compassion towards depression in pregnant women in Indonesia. Their results showed that with the increase of self-compassion and mindfulness, depression of women decreased [15]. Their results are consistent with our results. Thus, pregnant women with high levels of self-compassion are less likely to suffer from depression. In explaining this finding, it can be said that self-compassion reduces the level of depression by reducing isolation and self-criticism and increasing the sense of self-kindness and understanding of the common human experiences. Self-compassion helps a person cope better with difficult situations by increasing resilience. Self-love and acceptance of failures and shortcomings, without self-blame, can remove disorders such as depression, anxiety and stress and improve psychological health.
In the current study, dimensions of self-kindness, self-judgment, common humanity and over-identification had a role in predicting depression in pregnant women. Common humanity, and self-kindness had a negative relationship with depression, while over-identification, isolation, and self-judgment had a positive relationship with depression. Felder et al. conducted a study for determining the role of self-compassion in the psychological well-being of 189 pregnant and postpartum women, and showed that the severity of depression symptoms was directly related to self-judgment, isolation and over-identification, and was indirectly related to self-kindness, common humanity, and mindfulness [22]. Their results are consistent with our results. In general, it can be said that by accepting problems and failures as an inevitable part of human life and being aware of them without over-identification and exaggeration, the suffering caused by problems decreases and mental health increases. Self-judgment causes constant rumination and self-blame, thus making a person vulnerable to depression. Self-compassion makes a woman consider herself worthy of kindness, which can improve her mental health [13]. Self-compassion does not mean selfishness and preferring one’s own needs, but it means that a person, being aware of the pains and sufferings, accepts them as part of the human life and is kind to self without self-blaming [12]. The results of the studies by Rafiee et al., Farrokhzadian et al., Abdullahi Boqrabadi, Friis et al. showed that self-compassion-based training for people with depression reduce depression symptoms and improves mental health [16, 23-25]. Self-compassion is associated with a decrease in depression, stress, anxiety, and shame, and with an increase in happiness, self-confidence, life satisfaction, and physical health [26]. Self-compassion indirectly reduces depression and anxiety through perceived stress [27]. In people with high levels of self-compassion, the incidence of depressive symptoms is lower [18]. In fact, self-compassion is an important protective factor against emotional problems such as depression [28].
Based on the findings of this study, it can be concluded that self-compassion has a significant relationship with depression in pregnant women. This indicates the importance of providing mental health services using counseling or educational methods to pregnant women in comprehensive health centers to prevent their depression during pregnancy or reduce the symptoms and adverse effects. The results of this study can be used in designing educational and counseling programs for pregnant women. It is recommended to compare the effect of self-compassion training on depression during pregnancy with other psychological techniques in future studies using a larger sample size. One of the limitations of the study was the lack of examining marital problems and arguments in women because these factors can affect the symptoms of depression and the answers to the questionnaire. The high number of participants was one of the advantages of this study.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the ethics committee of  Kermanshah University of Medical Sciences (Code: IR.KUMS.REC.1402.006).

Funding
This study was funded by the Deputy for Research and the Student Research Committee of Kermanshah University of Medical Sciences.

Authors' contributions
Design: Bita Ashabi, Mastaneh Kamravamanesh and Nasreen Jabarqadri; Supervision: Mastaneh Kamravamanesh; Data collection and writing: Bita Ashabi and Ehsan Mahmoudi; Data analysis: Nader Salari and Bita Ashabi; Review, editing, and final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Deputy for Research and the Student Research Committee of  Kermanshah University of Medical Sciences, and all mothers and health care workers from the health centers in Kermanshah for their support and cooperation.



 

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