Adverse childhood experiences and depressive symptoms among pregnant women in Mongolia: The moderating role of protective and compensatory experiences in a cross-sectional study

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BACKGROUND: Depressive symptoms during pregnancy are common among expectant mothers, particularly in middle-income countries (MICs) with limited mental health resources. Adverse childhood experiences (ACEs) are established risk factors, but the role of protective and compensatory experiences (PACEs) remains understudied, especially in settings such as Mongolia. OBJECTIVE: To examine the associations between ACEs, PACEs, and elevated depressive symptoms among pregnant women in Mongolia, and to assess whether PACEs moderate this relationship. PARTICIPANTS AND SETTING: A cross-sectional study of 665 pregnant women in Ulaanbaatar, Mongolia, conducted from November 2024 to February 2025. METHODS: Participants completed an online questionnaire assessing ACEs, PACEs, and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Modified Poisson regression models were used to estimate associations and test moderation by PACEs. RESULTS: Elevated depressive symptoms were identified in 39.8% of participants. Overall, 73.6% reported at least one ACE, and 22.5% reported four or more. Greater ACE exposure was significantly associated with elevated depressive symptoms after adjusting for covariates. Although PACEs were highly prevalent, neither their direct association nor their interaction with ACEs was significant. Other factors associated with elevated depressive symptoms included intimate partner violence, lower income, and being single. CONCLUSION: ACEs were significantly associated with elevated depressive symptoms among pregnant women in Mongolia. Despite the high prevalence of PACEs, they did not moderate this relationship, possibly due to limited variability. These findings highlight the importance of screening for early adversity and depressive symptoms and integrating trauma-informed care into maternal health services in MICs.