We conducted a web-based cross-sectional survey among Norwegian pregnant women aged 18 years and older between January and March 2022. The survey was distributed on 6 Facebook (Meta Platforms) groups for pregnant women, organized by the due date, and 5 Instagram (Meta Platforms) accounts focused on pregnancy and childbirth. These groups and accounts had a combined total of 109,000 followers although many women were likely active on multiple platforms. For comparison, 51,292 women gave birth in Norway in 2022.

To promote the survey, we used an introduction video and postings. After publishing the survey on a new platform, all responses were received within 4 days. Data collection was closed after 2‐4 weeks for the different groups as we received no further responses. Of the 1402 women who answered the survey; 868 responses came from Facebook and 534 from Instagram. All participants consented to participate by answering the questionnaire, which included an information letter about the study. The study was anonymous, and the women were asked to respond only once. We followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), a quality checklist for internet-based surveys [39].

In the absence of validated questionnaires that fully met the study’s broader objectives, we developed a new one. We incorporated validated questions from previous surveys, including questions from the Cambridge Worry Scale and questions related to demographic variables, SRH and childhood experiences from the HUNT study [40,41]. The question “worries about money problems” in the Cambridge Worry Scale seemed somewhat unfamiliar within the context of the Norwegian welfare system. We chose to ask about capacity to manage an unexpected expense as this is easy to understand and has previously been used in Norwegian surveys [42]. In addition, the capacity to manage unexpected expenses of varying amounts has been defined as financial security; we chose NOK 10,000 (approximately US $1000) [43,44]. A total of 10 pregnant women were invited to pilot the survey for assessing completion time and question clarity, of whom 6 responded, suggesting minor linguistic adjustments. The questionnaire was administered by using a data collection tool (Nettskjema.no developed by the University of Oslo), which is user-friendly and compatible with various digital devices. The questionnaire contained up to 57 questions depending on the respondent’s answers, covering five different topics: (1) demographic variables, including sick leave and financial security; (2) assessment of SRH and SRMH, both during the current pregnancy and before pregnancy; (3) antenatal care, including visits to midwives, GPs, gynecologists, ultrasounds, and satisfaction with the controls; (4) sources where the women seek advice and information during pregnancy; (5) thoughts about the time after birth and the parental role, including assessment of own childhood. In total, 12 questions were open-ended with free text boxes, while the rest were closed-ended items. The complete questionnaire is translated into English and attached in Multimedia Appendix 1. This paper examines the parts related to health and attendance in the antenatal care program. Other parts of the project are published separately [45].

The questions concerning SRH were “Before you became pregnant, how would you characterize your own health?” and “How is your health now?” For SRMH, we asked, “Before you became pregnant, how were you feeling emotionally/mentally?” and “How are you feeling emotionally/mentally now during the pregnancy?” The answer options were very good, good, not so good, or poor in line with other studies [18,19], and were dichotomized for the logistic regression [46]. Participants were asked if they had been or were still on sick leave (used in cases of maternal illness) or maternity allowance (used when mother’s work could be harmful to the fetus). The questions regarding the socioeconomic status included the level of completed education and finances. We did not inquire about income. Instead, participants were asked if they could manage an unforeseen expense of NOK 10,000 (approximately 1000 USD), with response options of yes, uncertain, or no. We merged uncertain and no and defined that as “financial insecurity,” and yes as “financial security.” Furthermore, they were asked a single-item question to describe their childhood as either very good, good, average, difficult, or very difficult. We merged very good and good into good and difficult and very difficult into difficult. Antenatal visits were defined as the regular controls according to the Norwegian antenatal program. The women were asked if they had attended all of them, most of them, not attended, or not relevant (not been to the first control yet) with possible free-text answers for reasons for not attending. In addition, they were asked about the profession of the health care provider (GP, midwife, gynecologist, and others).

Data were analyzed using SPSS Statistics. The Pearson chi-squared test was used to examine associations between SRH and SRMH, and childhood experiences, financial security, parity, and attendance to antenatal care providers (GP or midwife). We further estimated the odds ratio (OR) of good SRH and SRMH using logistic regression models, and present crude associations as well as associations adjusted for age, education and trimester. While χ² tests allowed comparison of all four levels of SRH and SRMH, logistic regression allowed adjustment for potential confounders after dichotomizing perceived health. Most respondents answered all questions; data on trimester was missing for 2 participants, financial security for 2 and childhood experiences for 9 participants. All participants reported SRH and all but 1 SRMH. We performed complete case analyses and excluded those with missing responses from each analysis. Free text responses were analyzed for content and categorized.

A remit assessment was submitted to the Regional Committee for Medical Research Ethics in Central Norway (REK), which determined that formal ethics approval was not required under national regulations (reference 267956). The study was also approved by the Norwegian Centre for Research Data (NSD; reference 134424), which confirmed that no direct or indirect personal identifiers were processed. All procedures involving human participants were conducted in accordance with relevant national and institutional guidelines and regulations. An information letter, empathetically worded and based on a template provided by NSD, was distributed to all participants. Informed consent was obtained from all participants prior to data collection. No compensation was provided for participation.

Before pregnancy, 94.7% (1328/1402) of participants reported their health as either very good (35.2%, 494/1402)) or good (59.5%, 834/1402). During pregnancy, this combined percentage dropped to 67.8% (950/1402) (very good 13.7% (192/1402) and good 54.1% (758/1402). Conversely, the proportion of 5.3% (74/1402) reporting their health as either not so good (4.9%, 68/1402) or poor (0.4%, 6/1402) before pregnancy increased to 32.2% (452/1402) (not so good 28.2% (396/1402) and poor 4% (56/1402) during pregnancy. This indicates a significant decline in SRH (χ²₉=564.7; P<.001).

In Figure 1, we present the distribution of overall SRH during pregnancy, categorized by childhood experiences, socioeconomic factors (education and financial status), and parity. In Multimedia Appendix 3, we present crude and adjusted OR for good versus poor SRH. Participants who reported a good childhood had better SRH compared to those with average or difficult childhoods (70.2% [755/1076] vs 64% [114/178] vs 53.2% [74/139]; χ²₆=34.7; P<.001). This corresponds to 52% lower odds of good SRH for those with a difficult childhood (OR 0.48, 95% CI 0.34‐0.69), and the difference was robust to adjustment for age, education, and trimester (adjusted OR 0.52, 95% CI 0.36‐0.76; see Multimedia Appendix 3).

Women with financial security reported better SRH than those with financial insecurity (70.2% [819/1166] vs 55.6% [130/234]; P<.001), corresponding to 36% lower odds of good SRH for women with financial insecurity in the adjusted model (OR 0.64, 95% CI 0.47‐0.87). Higher education was also associated with better SRH (χ²₉=49.3; P<.001), with 76% lower odds for good SRH for those with only lower secondary school compared to 4 years or more of college or university (adjusted OR 0.33, 95% CI 0.16‐0.72). First-time mothers reported better SRH than mothers with previous births (73.9% [533/722] vs 61.4% [417/680]; P<.001), with 47% lower odds of good SRH for women with previous births (adjusted OR 0.53, 95% CI 0.41‐0.67).

Before pregnancy, 89.9% (1260/1402) of participants reported their SRMH as very good (33.8%, 474/1402) or good (56.1%, 786/1402). During pregnancy, this combined percentage dropped to 73.1% (1024/1401; very good 17.1% [239/1401] and good 56% [785/1401]). Conversely, while 10.2% (142/1402) reporting their SRMH as either not so good (9.3%, 130/1402) or poor (0.9%, 12/1402) before pregnancy, this increased to 26.9% (377/1401; not so good 23.1%, 323/1401) and poor (3.9%, 54/1401) during pregnancy. This indicates a significant decline in SRMH (χ²₉=365; P<.001).

Figure 2 shows the distribution of SRMH during pregnancy by childhood experiences, socioeconomic factors (education and financial status), and parity. Multimedia Appendix 3 shows crude and adjusted ORs for good SRMH. Participants who described their childhood as good reported better SRMH compared to those with average or difficult childhoods (76.7% [825/1075] vs 65.7% [117/178] vs 53.3% [65/139]; χ²₆=49.7; P<.001). This corresponds to 65% lower odds of good SRMH for those with a difficult childhood (OR 0.35, 95% CI 0.24‐0.56), and the difference was robust to adjustment for age, education, and trimester (adjusted OR 0.37, 95% CI 0.25‐0.54; see Multimedia Appendix 4).

The proportion of women reporting good or very good SRMH increased with longer education, except for the few (n=28) with only lower secondary school (78% [440/564] vs 73.1% [361/494] vs 64.4% [203/315] vs 71.4% [20/28]; χ²₉=30.2; P<.001). The odds of good SRMH were 45% lower for those with upper secondary school compared to those with more than 4 years of college or university (adjusted OR 0.55, 95% CI 0.40‐0.76). Women with financial security reported better SRMH than those with financial insecurity (75.9% [884/1402] vs 59.8% [140/234]; P<.001), corresponding to 46% lower odds for good SRMH for those with financial insecurity (adjusted OR 0.54, 95% CI 0.39‐0.74). First-time mothers reported better SRMH than mothers with previous births (77.4% [558/721] vs 68.5% [466/680]; P<.001), with 43% lower odds for good SRMH for women with previous births (adjusted OR 0.57, 95% CI 0.45‐0.73).

In total, 58.6% (820/1400) reported that they were or had been on sick leave so far during pregnancy (see Table 1), cumulating to 69.8% (366/525) among women in the third trimester (not shown in the table). Sick leave was strongly associated with SRH: 29.8% (57/191) of those reporting very good health, 53% (401/757) with good health, 80.6% (319/396) with not so good health, and 76.8% (43/56) with poor health were or had been on sick leave (P<.001). A similar pattern was observed for SRMH: 44.4% (106/239) of those with very good SRMH, 56.4% (442/784) with good SRMH, 70.5% (227/322) with not so good SRMH, and 83.3% (45/54) with poor SRMH were or had been on sick leave (P<.001). The proportion receiving maternity allowance remained stable at approximately 14% (197/1392; see Table 1) and was not affected by SRH (P=.99) or SRMH (P=.68).

Since nearly all attended the antenatal program (see Table 1), there was no numerical basis for analyzing whether the attenders had any different SRH than the nonattenders. 24 participants (1.7%) responded to an open-ended question about reasons for not attending all antenatal checkups thus far. The reasons for missing appointments were postponing due to illness (either their own or the health care personnel’s, such as COVID-19; n=9), being early in pregnancy and not yet needing a check-up (n=4), being advised by their health care provider to wait or experiencing a wait time for the first appointment (n=4), delaying due to vacation or other reasons (n=3), forgetting the appointment (n=2), or not needing a check-up because they received treatment at the hospital (n=2).

In total, 55.6% (753/1354) received shared care from both their GP and midwife, 38.4% (520/1354) had only been to a midwife and 6% (81/1354) to only their GP. The 13 % (177/1357) that had seen a gynecologist during pregnancy were mostly also seen by either a GP or midwife, and only 0.2% (3/1357) reported having solely been to a gynecologist (not shown in the table). We did a separately analyze for women in the 3rd trimester as they probably have been to most antenatal visits and found an even lower proportion women only seeing their GP (2.9%, 15/525) and only 0.2% (1/525) responded to neither have seen a GP nor midwife.

On a 5-point Likert scale, most participants were satisfied to a large or very large extent with the antenatal care visits (79.3%, 1079/1361). While the satisfaction levels were slightly lower for those who received antenatal visits solely from their GPs compared to those who had seemed midwife only or shared care, this difference was not statistically significant (70.4% [57/81] vs 81.7% [424/519] vs 78.9% [593/752]; P=.05). In addition, there were no notable differences in the proportion of participants reporting being satisfied to a little extent or not at all (3.7% [3/81] vs 3.5% [18/519] vs 3.6% [27/752]).

We analyzed the distribution of antenatal care visits based on SRH (see Figure 3) and SRMH (see Figure 4). The proportion of women receiving antenatal care solely from a midwife decreased as SRH declined, from 42.6% (78/183) among those with very good SRH to 27.3% (15/55) among those with poor SRH. The proportion receiving combined care increased correspondingly with poorer SRH, while the proportion receiving antenatal care solely from a GP remained low. These differences were not statistically significant across all 3 categories of attendance (χ²₆=9.1, P=.17). However, we additionally compared visits to GPs, either solely or as shared care, to visits solely to midwives, with results indicating a statistically significant difference (χ²₃=8.1; P=.04). We also examined antenatal visits by gynecologists, whether solely or in combination with primary health care, and found an increase from 13% among women with very good SRH to 23.2% with poor SRH (P<.001; not shown in Figure 3).

The proportion of women receiving antenatal care solely from a midwife remained stable for those with very good (39.3%, 90/129), good (38.8%, 292/412), and not so good (39%, 124/175) SRMH, but dropped for those reporting poor SRMH (24.5%, 13/53). However, this difference was not statistically significant, whether assessed across all 3 categories of attendance (χ²₆=6.2; P=.40) or comparing any visits to GPs to visits solely to midwives (χ²₃=5.2; P=.16). For gynecologists, there were no statistically significant differences by different SRMHs (P=.14; not shown in Figure 4).

We found that both SRH and SRMH were reported to be worse during pregnancy compared to before pregnancy. Women who had experienced difficult childhoods, had low socioeconomic status, or those who have given birth before reported poorer SRH and SRMH, even after adjusting for age, trimester, and education. Nearly all pregnant women participated in the antenatal program regardless of their health status. Both midwives and GPs played crucial roles in providing antenatal care, shared care being the most common type of care. Few women received antenatal visits exclusively from a GP. Notably, the proportion of women receiving antenatal care from a physician (either GP or gynecologist) increased slightly with declining SRH.

We consider the face validity of the questionnaire to be strong. This is supported by a successful pilot test with minimal feedback, and very few missing data, suggesting that participants found the study both relevant and well-aligned with its objectives. Although the authors developed the questionnaire, it contained several validated questions [41]. The questionnaire was anonymous, and participants had the opportunity to answer multiple times, as the data collection tool (Nettskjema.no) did not track IP addresses. Members of overlapping social media groups would receive an invitation for each group they belonged to. Although we considered this before the study began, we concluded that multiple responses from the same participant were unlikely, among other reasons because the survey was quite comprehensive. Furthermore, receiving all answers within few days lowers the risk of multiple responses. However, we cannot completely rule it out. Missing data was negligible and would not have substantially changed results, even if the missing data were not at random. Therefore, more advanced methods like multiple imputation were not considered. We collected data shortly after COVID-19 restrictions were lifted in Norway, and its possible that participants’ health and their recall of their health before pregnancy was still adversely affected by the pandemic [51,52].

Although we received 1402 responses, which is substantial, it represents only a portion of the 51,292 women who gave birth in Norway in 2022. Therefore, while we recognize the significance of our findings, we must remain cautious about the weight we assign to the results. Odds ratios are greater than risk ratios when the outcome is frequent and should not be read as the relative risk. The sociodemographic characteristics of the study population (age, parity, and marital status) were comparable to the general population of pregnant women in Norway, except for a lower proportion of immigrants. Findings therefore might not be generalizable to immigrants. Self-selection to participation might also depend on the included topics, such as worries and strategies for information seeking. The broad age categories increase the chances of residual confounding by age. Beyond these sociodemographic factors, it is challenging to evaluate the representativity of SRH and SRMH among our participants. Since SRH and SRMH were assessed retrospectively, recall bias could be a concern. However, it may have only been a few months since the participants were not pregnant. In addition, we expect recall of such broad concepts to be reasonably accurate, and our findings of their SRH align closely with average SRH reported in national statistics [8].

We used single-item measures for SRH to describe participants’ health. Although this subjective measure might seem simplistic and some nuances in variations in health may be lost, it is a comprehensive indicator that has been shown to correlate well with morbidity and mortality [4,81]. Furthermore, single-item SRMH correlates moderately with mental health scales and appears to be a robust measure of population mental health [82]. However, SRMH is not precisely defined, and assessment using the word “emotionally” in addition to “mentally” may have lowered the threshold for reporting poor SRMH, but overall, these single-item measures remain valuable tools for understanding the health status of our participants. Still, to get more comprehensive insights, future studies may consider incorporating multi-item scales.

Both SRH and SRMH were reported to be worse during pregnancy compared to before. Factors such as a difficult maternal childhood, low socioeconomic status, and previous childbirth were associated with poorer health during pregnancy. Both midwives and GPs played crucial roles in delivering antenatal care, shared care being the most common, however few women received care exclusively from GPs. The likelihood of physician involvement in care increased slightly with declining health. Recognizing these factors is essential for providing appropriate support and tailoring effective antenatal care.