Psychological Inflexibility and Suicidal Ideation in Pregnant Women: A Cross-Sectional Multiple Mediation Analysis of Depressive Symptoms, Insomnia, and Generalized Anxiety

Introduction: Suicidal ideation during pregnancy is an important public health concern. Psychological inflexibility may be associated with emotional and sleep-related symptoms linked to suicidal ideation; however, these patterns of association remain insufficiently understood in pregnant women. Objective: The objective was to examine the relationship between psychological inflexibility and suicidal ideation in pregnant women by evaluating the multiple mediating roles of depressive symptoms, insomnia, and generalized anxiety. Method: A quantitative, cross-sectional associative study using latent variables was conducted with 962 pregnant women receiving care at the National Maternal and Perinatal Institute (INMP), located in Cercado de Lima, Lima, Peru, between October and December 2025. Participants completed the Acceptance and Action Questionnaire-II (AAQ-II), Frequency of Suicidal Ideation Inventory (FSII), Athens Insomnia Scale (AIS), Patient Health Questionnaire-2 (PHQ-2), and Generalized Anxiety Disorder-2 (GAD-2). Structural equation modeling (SEM) was performed using R version 4.5.1 within the RStudio Version 4.5.1 environment. Results: The proposed model showed a good fit, scaled χ2(179) = 506.334, p < 0.001, robust CFI = 0.968, robust TLI = 0.963, robust RMSEA = 0.052, 90% CI [0.046, 0.057], and SRMR = 0.030. Psychological inflexibility showed a significant direct association with suicidal ideation (β = 0.246, p < 0.001) and significant indirect associations through depressive symptoms (β = 0.245, p < 0.001) and insomnia (β = 0.030, p = 0.007), whereas the indirect association through generalized anxiety was not significant (β = 0.007, p = 0.749). The total indirect association was significant (β = 0.282, p < 0.001), while the direct association remained statistically significant after inclusion of the mediators. Conclusions: Psychological inflexibility was associated with suicidal ideation among pregnant women, with depressive symptoms and insomnia showing significant indirect associations. These cross-sectional findings identify relevant correlates of suicidal ideation that warrant further longitudinal investigation.