This study was conducted to determine the relationship between perceived stress levels and healthy lifestyle behaviors of pregnant women in risk pregnancies based on the Neumann Systems Model. When evaluated for risk pregnancy characteristics based on obstetric history, current pregnancy, and general medical history, it was observed that women had numerous risks in all three areas. Studies indicate that women in high-risk pregnancies experience additional stress that can affect their health behaviors, particularly when considering low or high-risk pregnancy statuses [1, 3, 22].

The study included pregnant women who had been hospitalized due to hypertension or preeclampsia/eclampsia in their previous pregnancies. These conditions are hallmark indicators of high-risk pregnancies and are often associated with heightened maternal stress and systemic inflammation. Elevated stress in such contexts is believed to trigger neuroendocrine and inflammatory responses, which can impair fetoplacental circulation and increase the risk of adverse outcomes such as preterm birth and intrauterine growth restriction [15, 23]. This biologically plausible mechanism supports the idea that maternal psychological stress is not only a behavioral barrier but also a physiological risk amplifier. In line with this, Malakouti et al. (2015) reported a significant inverse relationship between perceived stress and health-promoting behaviors in women with preeclampsia, highlighting that elevated stress levels negatively affect self-care and lifestyle engagement. Similarly, our findings reveal that women with a history of hypertensive complications during pregnancy demonstrated lower scores in healthy lifestyle behaviors, particularly in areas such as physical activity and pregnancy responsibility. These results underscore the importance of integrated prenatal interventions targeting both psychological resilience and lifestyle regulation in high-risk pregnancies. Reducing maternal stress may not only improve mental well-being but also promote healthier behaviors that contribute to improved maternal-fetal outcomes.

In the study, the highest score was found in the Sociocultural/Developmental/Spiritual Life Domain Perceived Stress subscale of NSMT-RGASÖ. The literature shows that social support is associated with physical activity, healthy eating and interpersonal relationships [23]. It has also been reported that high-risk pregnant women exhibit the most positive health behaviours in the area of spiritual development [11]. The findings support that spirituality and sociocultural empowerment may be effective in coping with stress in high-risk pregnancies. It is also consistent with the literature that psychosocial health is affected by many factors [5]. Thus, the present findings support and extend previous studies and suggest that spiritual and sociocultural empowerment can play an important role in maintaining psychological balance under stress and promoting healthy lifestyle behaviors. Translating these findings into routine care practices may help health care providers make meaningful contributions to maternal and fetal health in high-risk pregnancies.

The mean score on the Healthy Lifestyle Behaviors in Pregnancy Scale (HLBPS) was above average, suggesting that despite being in high-risk groups, many pregnant women maintain a positive attitude toward engaging in healthy behaviors. These results are consistent with prior studies that reported similarly elevated HLBS scores among pregnant women [3, 6, 24, 25]. Pregnancy appears to function as a sensitive period during which women may be more receptive to health behavior interventions. This aligns with the Neuman Systems Model, which postulates that individuals under stress activate protective mechanisms to preserve systemic stability. In the study, it was found that age, education level and year of marriage significantly affected healthy lifestyle behaviours during pregnancy (p < 0.05). Regression analysis showed that age predicted healthy lifestyle behaviors significantly and positively (B = 2.674; p = 0.001). This finding shows that each 1 unit increase in age causes an average increase of 2.674 points in HLSB score. In addition, significant differences were found between the age of pregnant women and pregnancy responsibility, hygiene, physical activity, travelling and acceptance of pregnancy. The literature also supports that age is an important factor on health behaviours during pregnancy [1, 5].

Gökyıldız et al. (2014) reported that older and more educated women with higher socioeconomic status exhibited more health-promoting behaviors during pregnancy [26]. However, Cannella et al. (2018) noted that some high-risk groups displayed significantly lower health behavior scores [27]. In contrast, our sample demonstrated relatively higher scores. These discrepancies could be attributed to differences in study population characteristics, healthcare access, cultural norms, or regional variations in health literacy and social support.

Significant differences were found between the age of pregnant women, education level, years of marriage, and the total score of healthy lifestyle behaviors during pregnancy (p < 0.005). The literature indicates that age and education level influence the development of healthy lifestyles, with increasing age and education level correlating with higher average total scores on the HLBS scale [13, 24]. Our study parallels the literature. However, there are no studies in the literature showing a relationship between years of marriage and healthy lifestyle behaviors during pregnancy. The increase in healthy lifestyle behaviors with years of marriage may be interpreted as related to the adequacy in accepting pregnancy and taking on pregnancy responsibilities.

The results of this study indicate a relationship between the stress levels of pregnant women and their health behaviors. Dağlar et al. (2019) examined the relationships between coping styles with stress and quality of life in pregnant women, reporting a weak positive relationship between positive coping behaviors and quality of life, and a weak negative relationship between negative coping styles and quality of life [28]. Similarly, Kim and Lee found that pregnant women with lower stress levels engaged in more regular exercise compared to those with higher stress levels [29]. A systematic review also explained that anxiety and stress experienced during pregnancy are related to lifestyle and health habits [30]. Topaloğlu-Oren et al. (2023) reported a negative relationship between the level of depressive symptoms in pregnant women and their physical activity [31]. These results align with our findings.

In the study, it was found that the highest score in HLBS subscales was in nutrition and the lowest score was in physical activity. While nutrition is prioritised in preeclampsia and high-risk pregnancies, physical activity is ignored. Studies show that spiritual development and nutrition have the highest scores, while physical activity has the lowest score [3, 27]. However, physical activity in pregnancy is critical for maternal and infant health unless there is a contraindication [3]. On the other hand, Gökyıldız et al. (2014) found higher levels of physical activity in their study. This difference may be due to factors such as the geographical region where the study was conducted, the season, and health literacy. This finding requires a reassessment of cultural perceptions and support mechanisms regarding physical activity during pregnancy.

Finally, we observed a statistically significant inverse relationship between perceived stress and healthy lifestyle behaviors, affirming the findings of Malakouti et al. (2015) and Cannella et al. (2018). Cannella’s meta-analysis further emphasized that this negative effect of stress on health behaviors is amplified in high-risk pregnancies compared to low-risk ones. These data reinforce the need for psychosocial screening and stress reduction strategies in antenatal care, particularly among high-risk groups.

Limitations of the study

This study has several limitations. First, the classification of high-risk pregnancy was based on participants’ self-reports. Specific medical diagnoses such as gestational diabetes, preterm labor, or intrauterine growth restriction were not clearly identified. Second due to the cross-sectional design of the study, causal relationships between the variables could not be established. Longitudinal studies are needed to better understand these associations. Additionally, the study was conducted at a single center, which may limit the generalizability of the results. Multi-center studies with larger and more diverse samples are recommended.