Risk of postpartum anxiety and depression in women with a history of gestational hypertensive disorders

Abstract

BACKGROUND

Gestational hypertensive disorders (GHDs) are common pregnancy complications associated with severe maternal morbidity. Although their physical after-effects have been extensively reported, their effects on postpartum mental well-being, especially anxiety and depression, remain under-researched.

AIM

To evaluate the risk of postpartum anxiety and depression among women with GHD and assessed the protective role of a designed supportive care model.

METHODS

The participants were 220 women (110 with GHD; 110 normotensive controls) who were matched for key obstetric variables. Participants’ clinical and postnatal follow-up data were collected between June 2022 and May 2025. Standardized screening instruments were used to measure postpartum anxiety and depression between 6 and 12 weeks after delivery. Multivariable logistic regression was used to estimate adjusted odds ratios for postpartum mental health outcomes, accounting for relevant sociodemographic and obstetric confounders. Analyses in the hypertensive cohort examined the effect of structured supportive care models.

RESULTS

Women with GHD showed higher levels of postpartum anxiety and depression than normotensive controls. GHD was independently linked with higher odds of postpartum anxiety and depression after adjustment. Structured supportive care in the hypertensive cohort showed significantly lower prevalence and adjusted odds of postpartum anxiety and depression than in those who received standard postnatal care.

CONCLUSION

GHDs were associated with significantly elevated probabilities of postpartum anxiety and depression. Supportive care was associated with a significant reduction in this risk. Therefore, the introduction of specific psychosocial support into routine postpartum care for women with GHD should be considered.

Key Words: Gestational hypertensive disorder; Postpartum anxiety; Postpartum depression; Supportive care; Maternal mental health; Retrospective cohort study

Core Tip: This retrospective cohort study confirms that a history of gestational hypertensive disorders significantly increases the risk of postpartum anxiety and depression in women. A structured supportive care model effectively reduces this risk, suggesting that mental health interventions should be integrated into routine postpartum care for high-risk mothers to achieve comprehensive physical and psychological recovery.

INTRODUCTION

Gestational hypertensive disorders (GHDs), which include gestational hypertension and preeclampsia, are among the most common clinical problems involving pregnancy, with an estimated global incidence of 5%-10% of pregnancies. These complications are identified by the onset of hypertension beyond 20 gestational weeks and are linked to multisystem endothelial dysfunction, systemic inflammation, and placental ischemia. Significant evidence suggests that GHDs are associated with a range of adverse maternal and neonatal events, such as preterm birth, reduced fetal growth, and augmented long-term cardiovascular disease risk in mothers. Although the physical consequences of GHD have been meticulously documented, their psychological and mental well-being outcomes in the postpartum period have been relatively under-researched[1,2].

The postpartum period is a sensitive, high-risk period for maternal health, marked by significant physiological, hormonal, emotional, and social changes. Depression and anxiety are among the most common postpartum mental health issues faced by women. These conditions not only negatively impact maternal health but also have long-term adverse effects on family functioning and infants’ cognitive, emotional, and behavioral development. Postpartum mental health conditions often remain undiagnosed and undertreated, especially among women with complicated pregnancies[3,4].

Emerging evidence confirms that women with GHD face a high risk of developing postpartum depression and anxiety. Exposure to high-risk pregnancy, regular health monitoring, fear of maternal or fetal complications, emergent obstetric care, and anxiety about future health could all contribute to this psychological distress[5]. Previous studies have also demonstrated that stressors experienced during pregnancy - particularly in the third trimester - are significantly associated with postpartum symptoms of depression and anxiety[6]. Moreover, various biological processes - including recurrent inflammation, hypothalamic-pituitary-adrenal axis maladaptation, and vascular impairment, which are characteristic features of GHD - are now considered to play significant roles in the etiology of mood and anxiety disorders. The combination of such biological and psychosocial pathways explains the connection between GHD and negative postpartum mental health outcomes[7,8].

A higher incidence of depressive symptoms has been reported in women with a history of preeclampsia or gestational hypertension, although the results have been inconsistent across populations and study designs. Other studies have found no or low-order relationships with postpartum depression attributed to unadjusted confounding effects. Similarly, although postpartum anxiety is as common and important to clinical outcomes as depression, it has received considerably less attention in the context of GHD. This gap highlights the necessity for additional well-designed cohort studies to further investigate both anxiety and depression as outcomes that are independent but related within GHD[9,10].

In addition to risk identification, preventive and protective measures are also gaining momentum as methods of reducing the incidence of postpartum mental health disorders in high-risk groups. Supportive care models combining psychological counseling, improved clinical follow-up, patient education, and family or partner inclusion have been shown to be effective in preventing emotional distress during pregnancy and the postpartum period. In addition, emerging evidence suggests that internet-based interventions, including online cognitive-behavioural therapy and digital psychosocial support, can effectively improve mental health outcomes such as anxiety and depression[11]. These models are consistent with healthcare and patient-centered care frameworks focusing on the early detection of mental vulnerability and intervention. However, evidence is lacking on the effectiveness of supportive care in women with GHD, despite the heavy medical and psychological burdens they bear[12,13].

Traditional postpartum care for women with GHD is based on blood pressure (BP) monitoring, including hypertensive symptoms, and BP counseling about the future risk of cardiovascular disease. Mental health evaluation is typically not a priority or is even nonexistent, which prevents early diagnoses. Thus, the inclusion of organized supportive care in routine postnatal care could be a vital measure to enhance the health of such patients. Recent recommendations have paid increasing attention to the significance of mental health screening during obstetric care; nevertheless, empirical evidence regarding specific interventions for women with GHD is lacking[14,15].

To address these gaps in the literature, this retrospective cohort study examined the relationship between GHD and postpartum anxiety and depression. It also assessed the protective effects of a designed supportive model of care catering to the psychological, social, and emotional needs of mothers during the antepartum and postpartum periods. In doing so, this study intends to inform and guide evidence-based clinical practice and promote the inclusion of mental health services in the provision of comprehensive postpartum care for women with GHD.

Literature review

GHD and maternal health outcomes: GHD, including preeclampsia, are major maternal morbidity and mortality issues worldwide. These disorders result from abnormal placentation, defective spiral artery remodeling, and widespread endothelial cell dysfunction, which lead to systemic inflammation and vascular instability. Massive epidemiological studies have shown that women with GHD are at a higher risk of developing acute obstetrical complications, including placental abruption, postpartum bleeding, and emergent cesarean delivery. In addition to direct perinatal effects, there are growing indications that GHDs impose long-term health outcomes, such as chronic hypertension, ischemic heart disease, and cerebrovascular incidents, which redefine GHD as not only a pregnancy-limited illness but also a signal of systemic weakness[16,17].

Although the physical consequences of GHD are well-established, the psychological aspects of such disorders have not been adequately acknowledged. Complex pregnancies are typically characterized by frequent visits to hospitals, increased attention, and a lack of confidence in the baby and the mother. These stressors can have long-term psychological effects that can spill over into the postpartum period. Recent conceptual frameworks of maternal health outcomes increasingly integrate physical and mental health, suggesting that the vascular and inflammatory events underlying GHD can also affect neuromodulatory neurobiological processes[18].

Postpartum anxiety and depression: Prevalence and clinical significance: Postpartum anxiety and depression are mental health disorders that are highly prevalent in women in the postpartum period. Despite the significant focus on postpartum depression in both the clinical and academic communities, postpartum anxiety disorders, such as generalized anxiety, panic, and health-related anxiety, are now listed as both equally common and comorbid. According to population-based research, postpartum anxiety is common in new mothers, often coinciding with depressive symptoms, and contributes to functional impairment[19,20]. The psychological effects of postpartum anxiety and depression can be overwhelming. Affected women can have poor maternal–infant relationships, shorter breastfeeding and sleep duration, and lower quality of life. Infants of mothers with untreated postpartum psychiatric illness have a high risk of developing emotional dysregulation and delays in cognitive development, as well as antisocial behavior later in life. Nevertheless, despite these possible consequences, postpartum anxiety remains underdiagnosed, partially because of the presence of somatic factors associated with typical postpartum recovery and the specific emphasis of screening for depressive symptomatology[21].

Association between GHD and postpartum mental health: Recent literature has indicated a considerable correlation between GHD and poor postpartum mental health. Some cohort and case-control studies have found a higher incidence of depressive symptoms in women with preeclampsia than in their normotensive counterparts. The results remained similar after adjustment for sociodemographic and obstetric variables, suggesting that GHD can be considered an individual cause of postpartum psychological distress[7,22].

The connection between GHD and postpartum anxiety has not yet been extensively researched, but it has begun to be accepted as clinically significant. Women with GHD frequently report increased fear related to maternal death, birth complications, and future cardiovascular risk, which may persist throughout the postpartum period. The sense of loss of control, medical trauma, and subsequent uncertainty have been identified as major themes in postpartum women following preeclampsia and have been reported to cause a significant psychological burden beyond delivery[23].

Biological and psychosocial mechanisms linking GHD to mental health disorders: Various biological pathways have been identified to describe the relationship between GHD and postpartum anxiety and depression. GHDs are characterized by high concentrations of proinflammatory cytokines, oxidative stress, and destabilization of angiogenic factors. The pathogenesis of mood and anxiety disorders has also been attributed to the influence of these biological processes on neurotransmitter systems, neuroplasticity, and the regulation of the hypothalamic-pituitary-adrenal axis[24]. Neuroinflammatory explanations of depression suggest that systemic inflammation during gestation might predispose women to postnatal mood disorders, especially in preeclampsia[25].

Psychosocial factors enhance biological vulnerability. Extended hospital stays, early delivery for medical reasons, and admission of a newborn to neonatal intensive care are prevalent in women with GHD. They are independent variables correlated with postpartum psychological distress. In addition, issues related to the recurrence of hypertensive disorders during future pregnancies, as well as long-term cardiovascular risk, may leave women with anxiety long into the postpartum period. Overlapping biological and psychosocial pathways underscore the multifactorial occurrence of postpartum mental health risks in women with GHD[26].

Supportive care models in perinatal mental health: Supportive care models have become useful interventions for enhancing perinatal mental health, especially in high-risk groups. Psychoeducation, emotional support, continuity of care, and early detection of psychological disturbances are common elements in such models. Randomized and quasi-experimental research have shown that improved postnatal support (implemented by multidisciplinary teams) can be effective in preventing postpartum depression and anxiety or reducing their severity[27,28].

Despite their observed effectiveness, supportive care interventions are not commonly customized for medical pregnancy complications in women with GHD. Current postpartum care pathways tend to emphasize physical recovery and BP, ignoring psychological evaluations. Recent healthcare service research has recommended the incorporation of mental health support in obstetric follow-up in women with high-risk pregnancies and highlighted the necessity of proactive and non-reactive models of care[29].

Literature gaps and rationale for this study: Though the literature on GHD and postpartum mental health outcomes indicates a significant relationship, gaps remain. Most of the studies were either cross-sectional or relied on self-reported measures of symptoms without clinical validation, which restricts causal inference and lowers diagnostic accuracy. In addition, postpartum anxiety has received limited research attention compared to depression, even though anxiety can be an antecedent or a complication of depression. Moreover, few studies have assessed intervention strategies targeting women with GHD[7]. Our study attempts to bridge these gaps by using a retrospective cohort design with clinically recorded diagnoses and by considering both postpartum anxiety and depression as distinct outcomes; it also examines the protective role of a structured supportive care plan. This study can be applied to a more in-depth understanding of maternal mental health in the context of GHD due to its specific division of high-risk groups and inclusion of risk assessment as well as intervention analysis.

MATERIALS AND METHODS

Study design

This study used a retrospective cohort design to investigate the factors by which GHD are associated with postpartum anxiety and depression, as well as the factors by which a structured supportive care model is deemed protective. The retrospective method was chosen for the study’s systematic analysis of clinical and postnatal follow-up data, with reference to the time span, to compare women with GHD to normotensive controls outside clinical facilities. This design is suitable for measuring risk relationships and intervention outcomes in natural obstetric settings, where random allocation may be impossible.

Study setting and period

The research was conducted in a tertiary care maternity center/obstetric unit that offers all-line antenatal, intrapartum, and postnatal services, including high-risk pregnancy care. Clinical records and six-month postnatal follow-up data from deliveries were investigated between June 2022 and May 2025, a period chosen for its adequate sample size, similar clinical procedures, and consistent mental health screening practices in the research population.

Study population and sample selection

The study population comprised women who had singleton live births during the study period and had complete antenatal and postnatal records available for review. A total of 220 women were selected and divided into two cohorts. The exposed group consisted of 110 women with GHD, targeting both gestational hypertension and preeclampsia, recorded according to clinical criteria during the course of pregnancy. The control group included 110 women who had experienced no significant obstetric complications. Maternal age, parity, and mode of delivery were used to select controls in parallel to reduce confounding factors and for comparability. Women with chronic hypertension before pregnancy, a history of psychiatric disorders documented before pregnancy, multiple births, and perinatal loss were excluded to eliminate possible sources of bias and isolate the effect of gestational-onset hypertensive disorders on postpartum mental health outcomes.

Definition of exposure: GHD

GHDs were determined based on accepted obstetric diagnostic criteria reported in the medical records. Gestational hypertension was defined as new-onset systolic BP of 140 mmHg and/or diastolic BP of 90 mmHg beyond 20 weeks of gestation in the absence of proteinuria. Preeclampsia was characterized by hypertension beyond 20 weeks of gestation, accompanied by proteinuria or systemic involvement. The diagnosis was verified by attending obstetricians and documented uniformly in patient charts such that the exposure could be classified under the standard category.

Supportive care model

In the GHD group, a select segment of women received a guided supportive care framework through improved management during pregnancy and the postpartum period. This model was incorporated into daily clinical practice and concentrated on psychological, emotional, and social support along with medical care. The supportive care involved planned prenatal counseling (stress and coping skill development and pregnancy-related anxiety), delivery, intensive postnatal psychological screening, and planned follow-ups. Perinatal nurses and psychologists delivered the supportive care model. It consisted of: (1) At least two planned prenatal counseling sessions (each lasting 30-45 minutes) focusing on stress management and coping skills; (2) One postpartum psychological screening session using standardized tools; and (3) One educational session for family members on recognizing mental health symptoms. Frequency and content were standardized based on a structured protocol documented in the medical records. Family members participated in educational sessions to enhance their emotional support and postpartum awareness of mental health symptoms. Women who were unable to obtain this model received standard postnatal care focusing on physical recovery and blood sugar levels.

Outcome measures

Postpartum anxiety and depression were the major outcomes of interest. Participants’ time analysis was conducted at regular postnatal follow-up visits between six and 12 weeks after childbirth, a timeframe recognized as clinically pertinent for identifying postpartum mood and anxiety disorders. Trained healthcare professionals administered validated screening instruments regularly in the clinical setting, and anxiety and depressive symptoms were categorized as clinically significant using standardized cutoff scores aligned with established norms. The results were determined in binary terms as the presence or absence of a clinically significant symptom. Postpartum anxiety and depressive symptoms were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9, respectively. Trained healthcare professionals administered these validated screening instruments during routine postnatal follow-up visits. A Generalized Anxiety Disorder-7 score of ≥ 10 was considered indicative of clinically significant anxiety, and a Patient Health Questionnaire-9 score of ≥ 10 was used to define clinically significant depressive symptoms, in accordance with established cutoffs.

Covariates and potential confounders

Medical record data on maternal sociodemographic and obstetric factors were used to assess several variables that could have confounded the results: Maternal age, parity, body mass index (BMI) at booking, predelivery age, method of delivery, and neonatal birth outcomes. Covariates were chosen based on previous studies that list factors related to postpartum mental health and GHD. Adjusting for these variables enabled a more accurate estimation of the independent associations between GHD, exposure to supportive care, and postpartum mental health outcomes than would have been possible with uncorrected estimates.

Data collection procedures

A systematic review of electronic and paper-based medical records was performed to collect data using a standardized data extraction form. Obstetric records were cross-referenced with postnatal mental health assessments to ensure accuracy and timely completion. The potential for data entry error was reduced by having two independent researchers review the extracted information and resolve discrepancies by consensus. All data were anonymized before analysis to maintain patient confidentiality.

Statistical analysis

The baseline characteristics of the study population are summarized using descriptive statistics. Continuous variables were reported as means and standard deviations, and categorical variables as frequencies and percentages. Comparative analyses were performed between cohorts using appropriate statistical tests based on data distribution. Multivariate logistic regression models were developed to estimate adjusted odds ratios (AORs) and corresponding confidence intervals (CIs) for the relationship between GHD and postpartum anxiety and depression. Further regression analyses were conducted in the hypertensive group to assess the protective role of the supportive care model. Statistical significance was defined as a two-tailed P value < 0.05. The analysis was performed using standard statistical software. Given that matching did not fully balance all baseline covariates between the two groups, we used multivariate logistic regression, including key covariates [maternal age, BMI, parity, gestational age at delivery, mode of delivery, and neonatal intensive care unit (NICU) admission], to further adjust for residual confounding. This approach, while accounting for remaining imbalances, was preferred over a conditional regression model because the matching was performed on a limited set of variables, and complete balance was not achieved.

Ethical considerations

The Institutional Review Board provided ethical approval for the study. As this was a retrospective study, the requirement for informed consent was waived in compliance with institutional policies. All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki. Before analysis, patient identifiers, including IDs and names, were removed to prevent breaches of data confidentiality.

RESULTS

Baseline characteristics of the study population

Table 1 presents the baseline sociodemographic and obstetric features of the total study population. The average age of the maternal cohort was 29.8 ± 4.6 years, and about a fifth of the sample were women aged ≥ 35 years. More than half of the women were multiparous, and their average BMI before pregnancy indicated an overall overweight appearance. Preterm birth was observed in 20% of all participants, and cesarean section was performed in 39.1% of the preterm births. Admission to the NICU was observed in 16.4% of the newborns.

Table 1 Baseline sociodemographic and obstetric characteristics of the study population.

Variable	Total (n = 220)	mean ± SD/n (%)
Maternal age (years)	220	29.8 ± 4.6
Age ≥ 35 years	220	46 (20.9)
Primiparity	220	102 (46.4)
Multiparity	220	118 (53.6)
Pre-pregnancy BMI (kg/m2)	220	26.4 ± 3.8
BMI ≥ 30 kg/m2	220	48 (21.8)
Gestational age at delivery (weeks)	220	37.9 ± 2.1
Preterm delivery (< 37 weeks)	220	44 (20.0)
Vaginal delivery	220	134 (60.9)
Cesarean delivery	220	86 (39.1)
Neonatal birth weight (g)	220	3025 ± 485
NICU admission	220	36 (16.4)

BMI: Body mass index; NICU: Neonatal intensive care unit.

Table 2 shows the results of the comparative analysis of women with GHD and normotensive controls. Though no significant difference was observed in the maternal age of the population comprising the cohorts, higher BMI, high primiparity rate, high overall preterm delivery rate, and higher probability of cesarean section were seen among women with GHD. Infants born to women with GHD also had a significantly higher likelihood of requiring neonatal intensive care admission. These results confirm the increased obstetric risk profile of the cohort with hypertension and offer valuable contextualizing factors for elucidating postpartum mental health outcomes.

Table 2 Comparison of baseline characteristics between growth hormone deficiency and normotensive cohorts, n (%)/mean ± SD.

Variable	GHD (n = 110)	Controls (n = 110)	P value
Maternal age (years)	30.2 ± 4.7	29.4 ± 4.5	0.18
BMI (kg/m2)	27.8 ± 4.1	25.0 ± 3.2	< 0.001
Primiparity	58 (52.7)	44 (40.0)	0.04
Preterm delivery	30 (27.3)	14 (12.7)	0.006
Cesarean delivery	52 (47.3)	34 (30.9)	0.01
NICU admission	26 (23.6)	10 (9.1)	0.003

GHD: Gestational hypertensive disorder; BMI: Body mass index; NICU: Neonatal intensive care unit.

Figure 1 shows equal numbers of participants across groups, indicating balanced cohort sizes and supporting the validity of the comparative analysis.

Figure 1 Distribution of postpartum anxiety and depression between study cohorts. GHD: Gestational hypertensive disorder.

Prevalence of postpartum anxiety and depression

The prevalence of postpartum anxiety was 38.2% in women with GHD, compared with 18.2% in normotensive women, and 34.5% of women in the hypertensive cohort were found to experience postpartum depression, compared with 15.5% of the controls. These differences were considered statistically significant (Table 3).

Table 3 Prevalence of postpartum anxiety and depression by growth hormone deficiency status, n (%).

Outcome	GHD (n = 110)	Controls (n = 110)	P value
Postpartum anxiety	42 (38.2)	20 (18.2)	< 0.001
No anxiety	68 (61.8)	90 (81.8)	-
Postpartum depression	38 (34.5)	17 (15.5)	< 0.001
No depression	72 (65.5)	93 (84.5)	-

GHD: Gestational hypertensive disorder.

Figure 1 graphically illustrates these imbalances, showing significantly greater proportions of both anxiety and depression in women with GHD. The initial graphic division of the cohorts emphasizes the importance of the identified disparities and indicates that postpartum mental health is a major burden for women with hypertensive pregnancy complications. The findings suggest that GHDs are linked to a significant increase in exposure to postnatal psychological distress. The magnitude of these differences suggests that mental disorder sequelae are a clinically significant manifestation of the morbidity of GHD.

Unadjusted association between GHD and postpartum mental health outcomes

Table 4 shows the unadjusted associations between GHD and postpartum mental health outcomes, indicating that GHD led to odds of postpartum anxiety and depression almost threefold greater in women with GHD than in normotensive controls.

Table 4 Crude odds ratios for postpartum anxiety and depression associated with gestational hypertensive disorder.

Outcome	Crude OR	95%CI	P value
Postpartum anxiety	2.78	1.51-5.12	0.001
Postpartum depression	2.86	1.49-5.49	0.001

OR: Odds ratio; CI: Confidence interval.

These crude estimates indicate that the association between GHD and postpartum mental health outcomes was significant, even before the confounding factors were adjusted for. Nonetheless, given the observed variations in BMI, birth mode, and neonatal outcomes, multivariate adjustments must be made to establish whether GHD was an independent predictor of postpartum anxiety and depression.

Multivariable analysis of postpartum anxiety and depression

Table 5 presents AORs, the results of multivariate logistic regression models. GHD showed independent relationships with postpartum anxiety and depression, even when maternal age, BMI, parity, gestational age at delivery, mode of delivery, and NICU had been controlled.

Table 5 Adjusted odds ratios for postpartum anxiety and depression associated with gestational hypertensive disorder.

Outcome	Adjusted OR	95%CI	P value
Postpartum anxiety	2.71	1.45-5.05	0.002
Postpartum depression	2.89	1.52-5.48	0.001

Adjusted for maternal age, body mass index, parity, gestational age at delivery, mode of delivery, and neonatal intensive care unit admission. OR: Odds ratio; CI: Confidence interval.

Women with GHD who developed postpartum anxiety or depression had odds that increased 2.71- and 2.89-fold, respectively, after the control variables were considered. The CIs failed to cross unity, indicating strong statistical significance.

Figure 2 shows a forest plot of AORs and CIs. The pronounced divergence of both estimates on the null line suggests that GHDs have a more distinct effect on postpartum mental health outcomes than do common obstetric and demographic factors.

Figure 2 Forest plot of adjusted odds ratios for postpartum anxiety and depression. CI: Confidence interval.

These findings suggest that physiological stress, inflammatory load, and psychosocial strain linked to GHD may have enduring impacts on maternal mental health during the postpartum period. Such retention of importance following the adjustment indicates the value of viewing GHDs as risk factors rather than necessarily common contributors to poor obstetric outcomes.

Distribution of supportive care exposure among women with GHD

Table 6 shows the distribution of supportive care exposure cohorts in GHD. More than 50% of the women with GHD used the structured supportive care framework, whereas the rest used the standard postnatal care. With this relatively balanced distribution, a comparative analysis of postpartum mental health outcomes by type of care could be conducted.

Table 6 Distribution of supportive care exposure among women with gestational hypertensive disorder (n = 110).

Supportive care status	n (%)
Received supportive care	58 (52.7)
Standard postnatal care	52 (47.3)

Comparison of postpartum mental health outcomes by supportive care exposure

Women with GHD in the supportive care setup had a significantly lower prevalence of postpartum anxiety and depression than those in standard postnatal care; almost 50% of the women in the supportive care group showed neither anxiety nor depression, in contrast to only a quarter of women in the standard care group (Table 7).

Table 7 Postpartum anxiety and depression by supportive care status in the gestational hypertensive disorder cohort, n (%).

Outcome	Supportive care (n = 58)	Standard care (n = 52)	P value
Postpartum anxiety	16 (27.6)	26 (50.0)	0.01
Postpartum depression	15 (25.9)	23 (44.2)	0.02
No anxiety or depression	27 (46.5)	13 (25.0)	0.01

Figure 3 shows that the rates of postpartum anxiety and depression were lower among women who were provided with supportive care. The study sample enabled a visual comparison between groups that demonstrated the possible clinical advantage of organized psychological and social assistance in reducing postpartum mental health risks among women with GHD.

Figure 3 Postpartum mental health outcomes by supportive care exposure.

These results may indicate that the pathway to postpartum psychological morbidity is interrupted by supportive care interventions between the state of pregnancy-related stress and postpartum outcomes. The two notable decreases in anxiety and depressive symptoms indicate that the positive effects of supportive care affect a variety of aspects of maternal mental well-being.

Multivariable analysis of the protective effect of supportive care

Table 8 presents adjusted logistic regression analyses computing the protective effect of supportive care. Following the adjustment of a pertinent variety of maternal and obstetric variables, the exposure to supportive care was linked to a 58% decrease in the probability of postpartum anxiety or a 61% decrease in the probability of postpartum depression in women with GHD.

Table 8 Adjusted odds ratios for postpartum anxiety and depression associated with supportive care exposure.

Outcome	Adjusted OR	95%CI	P value
Postpartum anxiety	0.42	0.21-0.83	0.01
Postpartum depression	0.39	0.19-0.81	0.01

Adjusted for maternal age, body mass index, parity, gestational age, delivery mode, and neonatal intensive care unit admission. OR: Odds ratio; CI: Confidence interval.

Figure 4 displays a summary forest plot showing risk and protective factors of postpartum anxiety and depression, and incorporates these protective associations with the risk estimates. Close to the null line, the supportive care estimates with placed values all indicate a significantly high protective effect, which is the opposite of the high risk posed by GHD.

Figure 4 Summary forest plot of risk and protective factors. CI: Confidence interval; GHD: Gestational hypertensive disorder.

This article shows that supportive care not only alters symptom prevalence but also reduces risk independently of confounding factors. This implies that specialized psychosocial treatments can have a statistically significant effect on postpartum mental health outcomes in high-risk obstetric patients.

DISCUSSION

This retrospective cohort study offers strong evidence that women with GHD are much more likely to develop postpartum anxiety and depression, even after important socioeconomic and obstetric confounders are accounted for. These results add to the expanding body of literature that highlights GHD as a problem that is not temporary with only temporary obstetric outcomes, but that has long-term consequences on maternal mental well-being, even in the postpartum phase. This study provides an in-depth understanding of postpartum psychological vulnerability in women with GHD through a simultaneous analysis of risk and protective factors.

The fact that women with GHD developed a high prevalence of postpartum anxiety and depression is in line with prior research findings showing a relationship between pregnancy complications and eventual mental health outcomes. Longitudinal studies confirm that women who are exposed to medical stressors during pregnancy are more likely to develop psychological distress in the postpartum period, which can be associated with the hyperactivation of stress response systems during pregnancy[30,31]. Hypertensive disorders can now be characterized by high levels of monitoring, hospitalization, and doubts about the outcomes of the mother and fetus, which are potential causes of persistent anxiety after birth. These results support the idea that lasting complications are serious psychosocial stressors with permanent effects on mental health.

The association between postpartum mental health disorders and GHD can also be explained by biological processes. Hypertensive pregnancies are characterized by systemic inflammation, endothelial dysfunction, and changes in immune responses, all of which have been identified as having a role in the pathophysiology of mood and anxiety disorders. Neuroimmune theories suggest that high levels of inflammatory cytokines in the course of pregnancy may penetrate the blood–brain barrier or affect neural exit channels, making a person more susceptible to postpartum depression and anxiety[32,33]. Moreover, hypothalamic-pituitary-adrenal axis dysregulation, which is also frequent in women with hypertensive pregnancy disorders, could be carried into the postpartum period and lead to maladaptive responses to stress[34].

Psychosocial factors are likely to increase the risk of postpartum mental health problems in combination with biological vulnerabilities. Expectant mothers with GHD usually report loss of control, mortality anxiety, and traumatic birth experiences, especially when they have to undergo emergency cesarean section or admission of the newborn to the NICU. Qualitative and quantitative research has strongly connected such experiences with postpartum anxiety and depressive symptoms[35,36]. This study’s finding that GHDs were significantly correlated with postpartum mental health outcomes, even after other obstetric variables were adjusted for, indicates that psychosocial stressors have effects other than the variations that can be measured in obstetric factors.

One of the most significant contributions of this study is its assessment of the structured supportive care model as having a protective effect against postpartum anxiety and depression. Women with GHD who received supportive care showed a significantly lower prevalence and adjusted odds of anxiety and depression. These results are consistent with the literature on mental health in perinatal care, which highlights the importance of early psychological support, care continuity, and family support as means of decreasing and alleviating postpartum psychological distress[37,38]. Nevertheless, such interventions in the context of GHD are under-researched. This study is a significant addition to the literature.

The observed protective effect of supportive care can be understood through established psychological frameworks such as the stress-buffering model. According to this model, social support mitigates the adverse effects of stress by enhancing individuals’ appraisal of coping resources and directly reducing physiological stress responses. In the context of GHD, structured supportive care may interrupt the pathway from “disease-related stress” to “psychopathological symptoms” via several interrelated mechanisms. First, planned prenatal counseling may enhance maternal self-efficacy, the belief in one’s ability to manage pregnancy-related challenges, thereby reducing anticipatory anxiety and minimizing catastrophic thinking about complications. Second, involving family members in educational sessions may improve perceived social support, which has been consistently shown to buffer against postpartum depression and anxiety[39,40]. Third, intensive psychological screening enables early detection of subclinical symptoms, facilitating timely intervention before the symptoms escalate. The effect size of risk reduction represents a change in postpartum mental health trajectories in this high-risk population, consistent with the protective effects of supportive care interventions reported in the literature.

Overall, the results indicate the need to expand the scope of postpartum health care beyond physical recovery and BP normalization. Regardless of the growing awareness of perinatal mental health disorders, women with medical complications during pregnancy remain a neglected group in mental health screening programs because psychiatric history is placed above obstetric experience when it comes to risk assessment. This study’s findings support the initiative to incorporate mental health detection and assistance into integrated care models, in which mental health screening and support are formally implemented during the postnatal follow-up of women with GHD[41,42].

Other implications of this study concern health policies and service delivery. GHD are quite prevalent, and even minimal changes in mental health outcomes after childbirth may lead to substantial population-wide gains. Postpartum anxiety and depression imply higher healthcare costs, poor maternal functioning, and adverse developmental effects in children, all of which are costly to society[39,43]. Integrating the idea of structured supportive care for women with hypertensive pregnancies can thus be considered an efficient, potentially cost-effective approach to enhancing maternal and infant health.

Several limitations of this study must be acknowledged. A retrospective design makes it impossible to draw definitive causal conclusions and precludes ruling out residual confounding, even with multivariable adjustment. Instead of diagnostic interviews, screening instruments were used to determine mental health outcomes, thus potentially misclassifying symptom severity. Second, this study was conducted at a single tertiary care center that primarily serves patients with higher-acuity conditions that need more intensive management. Consequently, the observed prevalence rates of postpartum anxiety (38.2%) and depression (34.5%) may not be directly generalizable to GHD patients with milder disease who deliver at community hospitals or primary care facilities. Patients in tertiary centers may experience greater disease-related stress and treatment burdens, which could amplify psychological distress. Future multi-center studies involving diverse healthcare settings are required to validate the generalizability of our findings. In addition, the supportive care model was applied to one clinical environment, which may not apply to other health systems. However, the study’s matched-cohort research design, uniform assessment timeframe, and internal validity results were strengths that bolster confidence in the measured associations.

Future studies should build on these findings by conducting longitudinal analyses to evaluate the temporal associations between GHD and biological markers of stress and inflammation, as well as postpartum mental health trajectories. Randomized controlled trials comparing supportive care interventions in women with GHD would provide more causal and informative evidence of best practice. In addition, research on differences in the severity of gestational hypertension and preeclampsia could help identify more finely controlled risk-stratification policies.

CONCLUSION

Overall, this study provides strong evidence that gestational hypertension is a high-risk factor for postpartum anxiety and postpartum depression and establishes evidence that a supportive care framework offers a significant level of protection against these outcomes. These results indicate the necessity of considering mental health as part of the postpartum recovery of women with GHD and demonstrate the importance of including targeted psychosocial interventions in routine obstetric and postnatal care.