Pathways from prenatal anxiety to postpartum bonding difficulties in Pakistan: A prospective longitudinal study of psychosocial mediators and the buffering role of social support.

Background: Prenatal anxiety is common and may negatively affect the early mother-infant relationship, yet it has received less attention than perinatal depression, particularly in low-resource settings. The psychosocial pathways linking prenatal anxiety to postpartum bonding difficulties remain poorly understood. Methods: This prospective longitudinal study followed 501 pregnant women in Pakistan from early pregnancy (T1; 15-20 weeks gestation) to 8 weeks postpartum (T2). Prenatal anxiety was assessed using the Generalized Anxiety Disorder Scale-7 (GAD-7), and depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Late-pregnancy psychosocial stressors, including pregnancy experiences, domestic violence, and perceived stress, as well as perceived social support, were assessed at T1.5 (30-36 weeks gestation). Postpartum outcomes included mother-infant bonding difficulties measured by the Postpartum Bonding Questionnaire (PBQ) and postpartum anxiety symptoms. Longitudinal path analysis, parallel mediation, and moderated mediation models were conducted. Results: Prenatal anxiety significantly predicted postpartum bonding difficulties (β = .18, p = .001), independent of prenatal depressive symptoms. This relationship was partially mediated by late-pregnancy psychosocial stressors (total indirect effect = 0.34, 95% CI [0.23, 0.46]). Prenatal anxiety also demonstrated continuity with postpartum anxiety (β = .45, p < .001), which was associated with poorer bonding outcomes (β = .28, p < .001). Perceived social support moderated both direct and indirect pathways. Higher support weakened the direct association between prenatal anxiety and bonding difficulties (interaction β = -.13, p = .001) and reduced indirect effects through psychosocial stressors (index of moderated mediation = -0.07, 95% CI [-0.13, -0.02]). Conclusions: Prenatal anxiety is a distinct and clinically meaningful predictor of early mother-infant bonding difficulties. Its effects operate through persistent anxiety and heightened psychosocial stress, while perceived social support serves as an important protective factor. Interventions targeting prenatal anxiety, psychosocial stressors, and social support may help promote healthier mother-infant bonding in resource-constrained settings.