The precursors’s adaptation to pregnancy, prenatal attachment and maternal self-confidence

Abstract We investigated the precursors for prenatal attachment (PA), adaptation to pregnancy and maternal self-confidence, and the relationship of these variables with each other. This cross-sectional study was conducted between July and December 2020. Data were obtained using an online survey from social media groups. The mean Prenatal Self Evaluation Questionnaire scores of women had a negative and moderate correlation with mean Pharis Self-Confidence Scale (r=–0.287, p=.000) and negative and weak correlation with mean Prenatal Attachment Inventory scores (r=–0.317, p=.000). Women who conceived following assisted reproductive techniques had a higher level of readiness to give birth (17.62 ± 5.22) than women who conceived spontaneously (29.57 ± 6.15) (β=–0.285, t=–3.547, p=.002). We concluded that when women’s adaptation to pregnancy increased in the prenatal period, their PA level and self-confidence towards baby care increased. The results of this study may guide healthcare professionals in terms of improving care for women who have attachment and adaptation problems during pregnancy. Women who conceived following assisted reproductive techniques can be reassured that infertility does not have a negative impact on their readiness for birth. Healthcare professionals could ensure adaptation in women who have problems with adaptation during pregnancy by initiating interventions that support PA and increase the maternal self-confidence levels of women. Impact Statement What is already known on this subject? There were few studies examining the relationship between women’s conception style with prenatal attachment (PA), adaptation to pregnancy, and maternal self-efficacy. What do the results of this study add? In this study, it was determined that women who conceived following assisted reproductive techniques have higher levels of being ready to give birth than women who conceived spontaneously without medical assistance. Additionally, it was found that as women evaluate themselves positively in the prenatal period, their PA and maternal self-confidence level regarding baby care increased. What are the implications of these findings for clinical practice and/or further research? Since this study examines the precursors of maternal self-confidence, PA and adaptation to pregnancy in Turkish pregnant women, it was shown that studies in different cultures are needed in terms of generalisability of the results. In addition, there is a need to identify risky women who have low self-confidence in baby care during pregnancy and have attachment and adjustment problems, and to culture-specific intervention programs need to be developed and tested.


Introduction
Pregnancy is natural but complex event causing physiological, psychological and social changes, and requiring adaptation in the lives of women (Bjelica et al. 2018). A negative attitude towards pregnancy and the baby may developed in women, who have problems with adaptation to pregnancy (Çıtak Bilgin et al. 2019). Since healthy development of adaptation to pregnancy means increased health and well-being of women, foetuses and newborns, it is important for healthcare professionals to recognise a clear understanding of the associated factors affecting the adaptation to pregnancy. Especially, culture is an important variable in terms of affecting the maternal-foetal attachment process and the adaptation process to pregnancy (Foley et al. 2021). For example, infants are encouraged to explore their environment through tender care and distant eye contact in Western cultures, while infants' dependence on their mothers is fostered through maternal sensitivity, emotion-focused mother talk, and prolonged physical contact in Eastern cultures. Turkish culture, on the other hand, offers a unique heterogeneous context with interdependence and independence-oriented care (S€ umer et al. 2016). The questions that this research seeks to answer are, what are the precursors of adaptation to pregnancy, prenatal attachment (PA) and maternal self-confidence in Turkish pregnant women, and what is the determining level of conception type in particular.
One of the factors associated with adaptation to pregnancy is PA (C¸elik and G€ uneri 2020). Failing to ensure a safe PA during pregnancy may pose physical and mental risks for the life of the baby (Akarsu and Birg€ ul Alsaç 2017). It has been stated that as adaptation to pregnancy increases in high-risk pregnancies, PA increases, some sociodemographic and obstetric factors affect adaptation to pregnancy, and future studies are needed to determine the reasons for adaptation to pregnancy (C¸elik and G€ uneri 2020). Longitudinal studies from Turkey revealed that there is a positive and statistically significant relationship between PA and mother-infant attachment (C¸ınar et al. 2022), but no significant relationship with postpartum depression (Kaydırak et al. 2022). Recently, systematic review found that although lower levels of PA were associated with higher postpartum depression, different and conflicting results, especially in non-normative pregnancies such as assisted reproductive technology (ART), require careful interpretation of this situation (Roll� e et al. 2020). The reason for this difference in the literature may be due to the cultural and economically diverses in the study groups. In line with these conflicting results, it appears that a more comprehensive examination of the precursors of PA has been suggested.
Another factor affecting adaptation to pregnancy is the maternal self-efficacy (Yıldırım and Erci 2018). Previous studies found a positive and moderate correlation between maternal-foetal attachment and self-efficacy at Iranian (Delavari et al. 2018) and Egyptian women (Amasha et al. 2020). A cross-sectional study from Turkey showed that antenatal care increased the PA and childbirth self-efficacy levels of pregnant women (Bay et al. 2022). This result supports that maternal self-efficacy and PA may be related to each other.
The effect of the conception type on adaptation to pregnancy, PA and maternal self-efficacy has been examined in a limited number of studies (Chen et al. 2011, McMahon et al. 2011, Başg€ ol 2018. A recent review study showed that most couples who conceived following ART have a similar or even higher level of PA than couples who conceived spontaneously without medical assistance. Furthermore, this study emphasised the necessity of focussing more on pregnancyrelated issues because of the concerns of couples after successful ART, such as pregnancy loss (Ranjbar et al. 2020). In a recent study from Turkey, it was found that pregnant women who conceived following ART had lower adjustment to well-being of self and baby, and higher adjustment to identification with the role of motherhood and preparation for childbirth (Aksu and S¸atır 2022).
The literature contains studies examining the adaptation to pregnancy, PA and maternal self-confidence in pregnant women. However, this study is unique to our knowledge as it is the first study from Turkey to evaluate the precursors of adjustment to pregnancy, PA and maternal self-confidence.
The objective of this study is to investigate the precursors for adaptation to pregnancy, PA and maternal self-confidence, and the relationship of these variables with each other.

Materials and methods
A cross-sectional research design was used in this study. This study was conducted between July and December 2020 using an online survey due to the COVID-19 pandemic, the hospital environment made it difficult for women to focus on data collection.
We used the non-random convenience sampling method. The sample size was calculated based on the number of births (n ¼ 1,112,859) at Turkey in 2020 (https://data.tuik.gov. tr/Bulten/Index?p=Dogum-Istatistikleri-2020-37229). The sample size was estimated to be 165 pregnant women using the Raosoft web page based on 80% confidence level and 0.05 type I error (http://www.raosoft.com/samplesize.html). Hence, this study was conducted with a cohort of 164 pregnant women from seven regions of Turkey, (a) who were between ages 18 and 45 years old, (b) were at least primary school graduates, (c) conceived spontaneously without medical assistance, (d) conceived following ART, (e) had a healthy pregnancy period and (f) could speak and understand Turkish.
The social media groups opened specifically for women who became pregnant spontaneously and with ART, and where these pregnant women shared their knowledge, experience and practices, were determined by the researchers. The researchers sent a message to the site administrators, who opened these accounts, explaining the purpose, scope and method of conducting the study through their social media accounts. The research link was sent to the site administrators who agreed to share the link of the study on the social media pages, and the link was shared from the social media accounts opened specifically for pregnant women. The data were obtained from social media groups until reach a total of 164 pregnant women in which women conceived spontaneously without medical assistance and conceived following ART. In the study, the targeted number of participants for the two groups was not predetermined, and the survey was closed to the access of the participants as the sample number determined before the study was reached. The online questionnaire was developed by researchers based on literature (Delavari et al. 2018, C¸ıtak Bilgin et al. 2019 using Google Forms. Inclusion criteria are stated in the informed consent section of the online research form. Inclusion criteria are stated in the informed consent section of the online questionnaire. Based on self-report, pregnant women who stated that they wanted to participate in the study and met the inclusion criteria of the study were allowed to access the online questionnaire. The online questionnaire was completed by the participants. The response rate could not be calculated because an anonymous online survey was used in this study. In order to ensure the anonymity of the research, the names or contact information of the participants were not obtained in the online survey. The questionnaire was created in such a way that it does not contain any personally identifiable information. In the confidentiality of the research, the management of the online questionnaire was defined only to the research team. Data were collected using the Personel Information Form, Prenatal Attachment Inventory (PAI), Prenatal Self Evaluation Questionnaire (PSEQ) and Pharis Self-Confidence Scale (PSCS). The personal information form was prepared based on the relevant literature by the researchers. The form consisted of nine questions, including sociodemographic (such as age, gender and educational status) and obstetric characteristics (such as fertility type, previous pregnancy experiences and gestational week) of women.
The PAI was developed by Muller and Mercer (1993) to measure PA in terms of the unique affectionate relationship that develops between women and foetuses in the prenatal period. It consists of 21 items with four-Likert-type ranged from 1 (almost never) to 4 (almost always). The Turkish validity and reliability of the scale were conducted by Yılmaz and Beji (2013). The Cronbach alpha was found as 0.81 in the original version (Muller and Mercer 1993), 0.84 in the Turkish version (Yılmaz and Beji 2013) and 0.93 in this study. Total scores can range from 21 to 84, with high scores indicating higher levels of PA without a cut point.
The PSCS, developed by Pharis (1978), evaluates the parents' self-confidence in the daily care of the baby (Pharis 1978). It consists of 13 items with five-Likert-type ranged from 1 (not at all) to 5 (very much so). The Turkish validity and reliability of the scale were conducted by C¸alışır (2003). The Cronbach alpha was found as 0.85 in the original version (Pharis 1978), 0.84 in the Turkish version (Çalışır 2003) and 0.97 in this study. Total scores can range from 13 to 65, with high scores indicating higher levels of maternal self-confidence without a cut point.
The PSEQ was developed by Lederman (1979) to evaluate adaptation to pregnancy for women in the prenatal period (Lederman et al. 1979). It consists of 79 items with seven subscales. This scale was four-Likert-type ranged from 1 (not at all) to 4 (very much so). The Turkish validity and reliability of the scale were conducted by Beyda� g and Mete (2008). The Cronbach alpha was found as 0.81 in the Turkish version (Beyda� g and Mete 2008) and 0.93 in this study. Total scores can range from 79 to 316, with lower scores indicating higher levels of adaptation to pregnancy without a cut point.
This study was approved by the Akdeniz University Clinical Research Ethics Committee (no.: 459, date: 24 June 2020). The consent was obtained by women's approval via the button 'I agree to participate in the study' on the online survey according to the Declaration of Helsinki. Also, approval was obtained from the administrators of the social media platform before data collection.

Statistical analysis
The data were analysed with the support of statisticians using the SPSS Statistics Base v23 program package (SPSS Inc., Chicago, IL). The distribution of variables was tested for normality with kurtosis and skewness. The sociodemographic and obstetric characteristics were reported to use numbers, percentages, Chi-square and Student's t-test according to infertility type. The Chi-square test was used to find whether there was a difference between the spontaneous pregnancies and the infertility-treated pregnancies in terms of categorical variables. The correlation test was used to determine the relationship and level of relationship between continuous variables. Also, Student's t-test was used to determine whether there was a difference between spontaneous pregnancies and infertility-treated pregnancies in terms of continuous variables.
Multivariate regression analysis was separately applied using the PAI, PSCS and PSEQ as the dependent variables. Independent variables were selected using the forward stepwise method. The means, b, t and p values are given in the tables of multivariate regression analysis. The statistical significance value was taken as p < .05.

Results
This study was conducted with 164 pregnant women. A total of these women: 103 (62.8%) of them were spontaneous pregnant and 61 (37.2%) were infertility-treated pregnant. There was statistically no significant difference in terms of the socio-demographic and obstetric characteristics among the spontaneous pregnancies and infertility-treated pregnancies (p > .05). The sociodemographic characteristics of the participants are summarised in Table 1.

Prenatal Attachment Inventory
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the total mean of PAI scores (b ¼ 0.095, t ¼ 1.129, p ¼ .261). There was no statistically significant difference between the total score of the PAI and the socio-demographic and obstetric characteristic of women (p > .005) ( Table 2).

Pharis Self-Confidence Scale
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the total mean of PSCS scores (b¼0.004, t ¼ 0.048, p ¼ .962). Also, there was no statistically significant difference between the total score of the PSCS and the socio-demographic characteristic of working status, family type, economic level, and region of residence of women (p > .005). While a significant difference was found women' marriage year (b¼0.231, t ¼ 2.101, p ¼ .037) and education level (b¼0.220, t ¼ 2.436, p ¼ .016) with PSCS. It was determined that as the marital year of women increased, their self-confidence level regarding baby care increased (r ¼ 0.185; p ¼ .018), but it was found that this relationship provided a weak relationship. According to the education level, it was determined that the highest self-confidence level of women regarding baby care was in women with high school education (54.94 ± 12.89), then in university and above (52.36 ± 12.06) and the lowest in primary education (48.46 ± 12.05) ( Table 3).
While a significant difference was found between PSCS and previous pregnancy experience (b ¼À 0.254, t ¼ À 2.872, p ¼ .005), it was determined that there was no significant difference with the current gestational week (b¼À 0.127, t ¼ À 1.670, p ¼ .097) in terms of obstetric characteristics of women. The total mean PSCS score for women with previous pregnancy experience was 56.31 ± 10.44, and the total mean score for women without previous pregnancy experience was 49.37 ± 12.55. It was determined that women with previous pregnancy experience have higher self-confidence levels regarding baby care than women without previous pregnancy experience (Table 3).

Prenatal Self Evaluation Questionnaire
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the total mean of PSEQ scores (b¼0.066, t ¼ 0.809, p ¼ .420). Additionally, there was no statistically significant difference between the PSEQ total score with socio-demographic and obstetric characteristics of women (p > .005). However, a significant difference was found between the economic level of women and the total mean PSEQ score (b¼À 0.257, t ¼ 3.242, p ¼ .001). It was determined that women who said 'income is less than expenses' (156.20 ± 20.56), according to their income level, evaluated themselves more negatively in the prenatal period than women who said 'income is equal to expenses' (137.56 ± 28.01) and 'income is more than expenses ' (129.37 ± 26.77). In this context, it can be said that as the income level of women decreases, they evaluate themselves more negatively in the prenatal period (Supplementary Table 4).

Opinions of the individual related to the health of herself and her baby
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the total mean of opinions of the individual related to the health of herself and her baby subscale score (b¼À 0.185, t ¼ À 1.953, p ¼ .050). There was only a statistically significant difference between the opinions of the individual related to the health of herself and her baby subscale score and the education level of women (b¼À 0.185, t ¼ À 1.953, p ¼ .050). According to the education level, women who have an education at the high school level (26.00 ± 7.02) regarding the health of women and their babies have a more negative perception than women who have primary education (24.54 ± 6.90) and university and higher education (24.48 ± 6.78) (Supplementary Table 4).

Accepting the pregnancy
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the accepting the pregnancy subscale score (b¼0.012, t ¼ 0.149, p ¼ .882). There was a statistically significant difference between the accepting the pregnancy subscale score and the economic level (b¼À 0.236, t ¼ À 3.095, p ¼ .002) and region of residence (b¼À 0.231, t ¼ À 1.052, p ¼ .021) of women. It was determined that women who said 'income less than expenses' (26.53 ± 8.00) according to their income level had lower levels of pregnancy acceptance compared to women who said 'income is equal to expenses' (23.01 ± 7.11) and 'income is more than expenses' (20.72 ± 6.25). In this context, it can be said that as the income level of women increases, the level of pregnancy acceptance increases. According to the region they live in, it was determined that the pregnancy acceptance level of women living in the Mediterranean region (25.21 ± 7.31) was the lowest, and the highest in the Southeastern Anatolia region (19.00 ± 2.51) (Supplementary Table 4).

Accepting the role of motherhood
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the accepting the role of motherhood subscale score (b¼0.014, t ¼ 0.168, p ¼ .867). There was a statistically significant difference between accepting the role of motherhood subscale score and the education level (b¼À 0.251, t ¼ À 2.746, p ¼ .007) and economic level (b¼À 0.171, t ¼ À 2.163, p ¼ .032). It was found that women with primary education level (28.77 ± 5.90) regarding the acceptance of women's maternal roles have a more negative perception than women with high school (25.55 ± 6.14) and university or higher education (24.46 ± 6.52). As a result, it can be said that the higher the education level of women, the higher the acceptance of motherhood roles. According to their income levels, it was determined that women who said 'income is less than expenses' (28.47 ± 5.80) have lower acceptance of maternal roles than women who say 'income is equal to expenses' (24.84 ± 6.63) and 'income is more than expenses' (23.18 ± 6.31). In this context, it can be said that as the income level of women increases, the level of acceptance of the motherhood role increases (Supplementary Table 4).

Being ready to give birth
The total mean of being ready to give birth subscale score of the spontaneous pregnancies was found to be 29.57 ± 6.15, and that of the infertility-treated pregnancies 17.62 ± 5.22. Multivariate regression analysis showed that infertility-treated pregnancies have higher levels of readiness to give birth than spontaneous pregnancies (b¼À 0.285, t ¼ À 3.547, p ¼ .002). There was statistically significant difference between being ready to give birth subscale score and the economic level (b¼À 0.206, t ¼ À 2.525, p ¼ .013). It has been determined that women who say 'income is less than expenses' (20.33 ± 5.83), 'income is equal to expenses' (17.34 ± 4.31) and 'income is more than expenses' (17.04 ± 4.37) are found to be lower than women who say 'income is less than expenses' according to their income levels. In this context, it can be said that as the income level of women increases, their readiness for birth increases (Supplementary Table 4).

Fear of childbirth
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the accepting the fear of childbirth subscale score (b¼0.070, t ¼ 0.840, p ¼ .402). There was a statistically significant difference between the fear of childbirth subscale score and the economic level (b¼À 0.308, t ¼ À 3.839, p ¼ .000). It was determined that women who said 'income is less than expenses' (23.87 ± 3.89), 'income is equal to expenses' (20.44 ± 4.84) and 'income is more than expenses' (18.58 ± 4.56) were found to be higher in terms of their income levels. In this context, it can be said that as the income level of women increases, their level of fear of childbirth increases (Supplementary Table 4).

Relationship with her mother
The total mean of the relationship with her mother subscale score of the spontaneous pregnant women was found to be 15.85 ± 5.31, and that of the infertility-treated pregnancies 18.13 ± 7.77. Multivariate regression analysis showed that women who conceived following ART had a more negative relationship with their mothers during pregnancy than did women who conceived spontaneously without medical assistance (b¼0.181, t ¼ 2.184, p ¼ .030). Also, there was a statistically significant difference between the relationship with mother subscale score with previous pregnancy experiences (b¼À 0.225, t ¼ À 2.474, p ¼ .014). It was determined that women who had previous pregnancy experiences (18.38 ± 6.70) had a more negative relationship with their mothers during pregnancy than women who did not experience pregnancy (15.45 ± 5.91) (Supplementary Table 4).

Relationship with her husband
Multivariate regression analysis showed that there was no statistically significant difference between the spontaneous pregnancies and infertility-treated pregnancies in terms of the accepting the relationship with her husband subscale score (b¼0.040, t ¼ 0.470, p ¼ .639). Additionally, there was no statistically significant difference between the relationship with her husband subscale score with obstetric and sociodemographic characteristics of women (p > .005) (Supplementary Table 4).

Relationship between prenatal attachment, selfconfidence and self-evaluation
It was determined that there was no statistically significant relationship between the PAI mean score and the PSCS mean score of the women (r ¼ 0.063; p ¼ .423). However, it was found that there is a moderate correlation between the PSEQ mean score and the PSCS mean score (r ¼ À 0.317; p ¼ .000) and weak correlation between the PSEQ mean score and PAI score of the women (r ¼ À 0.287; p ¼ .000) (Supplementary Table 5). In this context, it was determined that as women evaluate themselves positively in the prenatal period, their PA and self-confidence level regarding baby care increased.

Discussion
This study was conducted to determine the precursors for PA levels, adaptation to pregnancy and maternal self-confidence, and the relationship of these variables with each other. It is unique as we know in terms of being the first study from Turkey, where adaptation to pregnancy, PA and maternal self-confidence were evaluated together. In this study, it was found that the conception type did not affect the levels of adaptation to pregnancy, PA or maternal self-confidence in pregnant women. On the other hand, when women who conceived following ART were compared to the women who conceived spontaneously without medical assistance, it was determined that they had higher levels of their being ready to give birth, and more negative relationships with their mothers. Being pregnant with a desired baby is generally regarded as a pleasing event, especially for women with a history of infertility, and who spend more emotional, physical and economic effort accordingly (Boz et al. 2018). Women who conceived following ART are assumed to have high levels of adaptation to pregnancy and PA due to their longterm expectation and desire to have a baby (Boz et al. 2021); however, it is one of the notable results of this study that the medical history of infertility does not affect adaptation to pregnancy and PA. In a recent longitudinal study from Iran, it was found that pregnant women who conceived following ART in the third trimester of pregnancy were attached to their foetuses like fertile women (Ranjbar et al. 2021). Also, in a study from Switzerland, no difference was found between the PA levels of women who conceived following ART, and women who conceived spontaneously without medical assistance (Udry-Jørgensen et al. 2015). However, in an Italian study, higher levels of PA were found in women who conceived spontaneously without medical assistance (Pellerone and Miccich� e 2014). Previous studies supported that women who conceived following ART had major difficulties in perceiving themselves as pregnant (Crespo and Bestard 2016), and therefore, they continued to perceive themselves as different from other pregnant women (Huang et al. 2019). In a recent qualitative systematic emphasises, the importance of understanding the ambiguity and ambivalent feelings that women who conceived following ART have about the delay in attachment development to the foetus and the formation of maternal identity (Maehara et al. 2022). Different results achieved in the previous studies may be associated with the difference of the study groups and their cultural differences.
We determined that women who conceived following ART had more negative relationships with their mothers during pregnancy compared to the women who conceived spontaneously without medical assistance. Contrary to the results of our study, it was concluded that women with previous experience of pregnancy had more positive relationships with their mothers during pregnancy compared to the women with no previous experience of pregnancy in a Turkish study (Yıldırım and Erci 2018). On the other hand, no statistical difference was found between the scores obtained from the sub-dimension of relationship with their own mother in terms of ART-treated, infertility-treated and spontaneous pregnancies in an another study from Turkey (Başg€ ol 2018). It is recommended to perform a detailed analysis on the relationship between the conception type and satisfaction with the relationship with their mother, and the reasons for having more negative relationships with their mothers in women who conceived following ART, compared to the spontaneous pregnancies.
In our study, levels of being ready to give birth of infertility-treated pregnant women were found to be higher compared to the women who conceived spontaneously without medical assistance. Similarly, in a study from Turkey, it was determined that pregnant women who conceived following ART were more likely to identify with the role of motherhood, preparation for childbirth and birth control (Aksu and Şatır 2022). It may be assumed that it is inevitable for women who conceived following ART to feel more prepared for childbirth towards the end of pregnancy, the fact that they define pregnancy as a long-term dream that has become real, and as the award of a challenging treatment process. Nonetheless, couples who conceived following ART, mentioned that they had difficulty in preparing for childbirth and parenthood due to the fear of losing the baby in a qualitative study from England (French et al. 2015). Women who conceived following ART were determined to be unprepared for motherhood in an another qualitative study from USA (Ladores and Aroian 2015). No statistically significant difference was found between spontaneous pregnant and infertility-treated pregnant women in terms of being ready to give birth in a Turkish study (Başg€ ol 2018). In addition, it was found in our study that there was no difference between women who conceived spontaneously without medical assistance, and women who conceived following ART in terms of childbirth fear. No study was reached to examine the relationship between conception type and fear of childbirth. In this study, it was found that the conception type did not affect the maternal self-confidence levels of pregnant women. It was found that women who conceived twin babies with IVF treatment had lower maternal self-confidence levels compared to spontaneous pregnancies in a study (Baor and Soskolne 2010). It is assumed that this difference may have occurred due to the fact that the pregnant women had high levels of anxiety about the maternal care for twins. It is recommended to examine the relationship between being ready to give birth and fear of childbirth with conception method in more detail.
We found that, as the levels of adaptation to pregnancy increased in women, their levels of PA and maternal self-confidence also increased. Similar with the results of our study, the increase in the levels of adaptation to pregnancy in women was found to result in an increase in their PA (Çelik and G€ uneri 2020) and maternal self-efficacy levels (Yıldırım and Erci 2018). Healthcare professionals may ensure adaptation to pregnancy in women who have problems with adaptation during pregnancy by initiating interventions that support PA during pregnancy and increase the maternal selfconfidence levels of women.
The strengths of this study are that deals with the precursors of adjustment to pregnancy, PA and maternal self-confidence together, and presents a sample profile from all regions of Turkey. Besides, present study had certain limitations. Since the study was conducted during the COVID-19 pandemic, women's adaptation to pregnancy, attachment to their babies and maternal self-confidence may have been affected. However, this study did not focus the effects of COVID-19 pandemic on women's adaptation to pregnancy, attachment to their babies and maternal self-confidence. Also, data were obtained online from social media platforms due to the COVID-19 pandemic. The data represent a population that is a member of these platforms and has a higher socio-economic and educational level. Therefore, the results of the study can be generalised to women with a high level of education. Additionally, the number of participants from the regions of our country is not equal. This situation constitutes an obstacle to the clarification of cultural differences. Then, the number of women, who conceived following ART and who conceived spontaneously without medical assistance, has not been equal. In this case, it weakens the generalisability of the study results. Because we used the nonrandom convenience sampling method, the results can still not be generalised for whole pregnant women (high-risk pregnancies and donation pregnancies).

Conclusions
The synthesised results showed that as women's adaptation to pregnancy increased in the prenatal period, their PA level and self-confidence towards baby care increase. Also, it was determined that as the marital year, education level and previous pregnancy experiences of women increased, their self-confidence level regarding baby care increased. This study was determined that fertility type made a difference in terms of readiness for birth, and women who conceived following ART had higher levels of readiness for birth than women who conceived spontaneously without medical assistance.
Healthcare professionals need to be aware of the specific care needs of women that have problems with PA and adaptation to pregnancy. It is believed that the results obtained in this study may guide healthcare professionals who aim to protect and improve health in terms of the services they will provide for these women. Since this study examines the precursors of maternal self-confidence, adaptation to pregnancy, and PA in Turkish pregnant women, studies from different cultures are needed in terms of the generalisability of the results. In addition, more studies are needed on the review of healthcare policies, the development and implementation of intervention programs for women who have attachment and adaptation problems during pregnancy. It is recommended to examine the fathers and relatives dimensions of precursors of maternal self-confidence, adaptation to pregnancy, and PA. Longitudinal studies of precursors related to adaptation to pregnancy, PA and maternal self-confidence in pregnant women are also recommended.

Author contributions
Conception and design of the study: GT; acquisition of data: GT, MA and IB; data analysis: GT and MA; interpretation of data: MA and IB; drafting the article: GT, MA and IB; final approval: GT, MA and IB.

Disclosure statement
No conflict of interest was declared by the authors.

Funding
The author(s) reported there is no funding associated with the work featured in this article.

Data availability statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.