Impact of Work from Home Policy during the COVID-19 Pandemic on Mental Health and Reproductive Health of Women in Indonesia

Abstract

Objectives: This study aimed to assess the impact of work from home (WFH) during the COVID-19 pandemic on the mental health and reproductive health of women in Indonesia. To the best of our knowledge, this is the first study evaluating the impact of WFH policy on said health aspects in Indonesia.

Methods: We conducted an observational study with a cross-sectional approach using an online survey among premenopausal married women in Indonesia. The survey included the General Health Questionnaire (GHQ-12) for psychological distress, average sexual intercourse frequency (SIF) per week, contraception use, change of menstrual pattern, and desire for having children. To analyze the effect of WFH, the participants were divided into groups based on their WFH compliance: (1) Both couples (her and her spouse) work from home, (2) Only the wife works from home, (3) Only the husband works from home, and (4) Neither works from home.

Results: 348 women were included in this study. Psychological distress occurred in 48.0% (n = 167) participants. No significant difference was found between the WFH groups (χ²[3, N = 348] = 2.077, p = .56)). The average weekly SIF was found to be significantly fewer during WFH (T = 5014, z = −5.598, p < .001). However, only 22.7% (n = 79) participants reported the use of contraception and 52.9% (n = 196) participants still wanted to have children. Change of menstrual pattern occurred in 31.6% (n = 110) participants and were significantly correlated to psychological distress (r_s= .126, p = .018).

Conclusions: WFH does not aggravate the effect of the pandemic on women's mental and reproductive health in Indonesia. A significant number of them still desire to have children and contraceptive prevalence is low.

Background

The World Health Organization (WHO) declared COVID-19's status as a pandemic on March 11, 2020 (World Health Organization, 2020). By the time of this writing, the number of COVID-19 cases in the world has reached 6 million cases. The COVID-19 pandemic has caused high mortality rate and many negative impacts on several aspects of health. However, we must also take notice of the potential impact on morbidity and social impacts that may be arising, either due to the pandemic itself or the policies undertaken to address it (Bavel et al., 2020; Walker et al., 2020). To lessen the increasing rate of COVID-19 cases, the Indonesian government has implemented several policies,one of which is the work from home (WFH) initiative for both private and government employees (Djalante et al., 2020).

Previous public health emergencies were associated with psychological distress and symptoms of mental illness (Bao et al., 2020). A recent meta-analysis showed relatively high rates of symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and stress during the COVID-19 pandemic (Xiong et al., 2020). Moreover, many mental health experts are concerned that WFH policies will aggravate the mental health burden on society (Brooks et al., 2020). Workers who carried out WFH on a regular basis before the COVID-19 pandemic were reported to suffer from higher levels of stress compared to working from the office (Boehmer et al., 2007). Work-related stress is known to be able to cause an increased risk of depression and anxiety in working women and men (Melchior et al., 2007). The COVID-19 pandemic also causes household income loss to many people, increasing anxiety and depression. Females with chronic conditions and living with 3−5 family members also reported lower quality of life (Tran et al., 2020), which will be aggravated by the confinement due to COVID-19 ( Biviá-Roig et al., 2020). Work from home also increases the chance to have more exposure to news and information about COVID-19, leading them to worry more about it (Gao et al., 2020; Huang & Zhao, 2020).

Women’s reproductive and sexual health is believed to may also be negatively affected by the pandemic (Hussein, 2020). Previous public health emergencies showed that public health emergencies have a negative effect on women's reproductive and sexual healthcare (Davies & Bennett, 2016). In addition to impeding access to reproductive health services, disaster events are known to change women's reproductive behavior patterns. A study of women affected by the earthquake in Wenchuan found a significant decrease in sexual intercourse frequency (SIF), sexual life satisfaction, and desire to have children following the disaster (Liu et al., 2010). Indonesian National Population and Family Planning Board (BKKBN) voiced their concern about the incoming baby boom following the COVID-19 pandemic, based on their finding of decreasing contraception use during the pandemic (Badan Kependudukan dan Keluarga Berencana Nasional, 2020).

The adoption of the WFH policy still garners controversy from policymakers and the health community. Many fear it might worsen the effects of the pandemic (Brooks et al., 2020), and induce a baby boom (Badan Kependudukan dan Keluarga Berencana Nasional, 2020). Based on the data from previous studies relating to the COVID-19 pandemic and other disasters (Wang et al., 2020; Le et al., 2020; Le et al., 2020; Tee et al., 2020), we hypothesized that significantly more time spent at home due to the enforced policy during the pandemic would cause significant psychological distress in the subjects. We also hypothesized that due to WFH, considerably more time spent at home together between married couples will lead to an increase in sexual intercourse frequency (SIF). Therefore, this study aimed to assess the impact of WFH during the COVID-19 pandemic on the mental health and reproductive behavior of married women in Indonesia.

Materials and methods

Study design

We conducted an observational study with a cross-sectional approach using an online survey to investigate the effects of WFH during the COVID‐19 pandemic on the mental health and reproductive behavior of married women. The survey was conducted for two weeks in April 2020 using Google Form, distributed through social media, namely Instagram, Twitter, and WhatsApp groups. We compared the participants’ psychological distress using the 12-item General Health Questionnaire (GHQ-12) (Idaiani & Suhardi, 2006), the average SIF per week in 1 month before (before 16 March 2020) and 1 month after the WFH policy in Indonesia was enacted, contraception use, change of menstrual pattern from before and after the WFH policy was enacted, and desire for having children during the pandemic. We also collected sociodemographic data such as age, length of marriage, educational background, and the number of previous pregnancies, parity, abortion, and children. The participants were also asked whether they and their spouses implemented WFH. Due to the cross-sectional design, the participants were only surveyed once during the pandemic and the data before the pandemic were based on memory recall.

Ethical approval

We comply with the American Educational Research Association (AERA) Code of Ethics as guideline for ethical issues in making and conducting the online survey (American Educational Research Association, 2011). All participants in this study have given informed consent before participating in the online survey. Ethical approval was granted by the Ethical Committee of Widya Mandala Catholic University (No. 089/WM12/KEPK/DOSEN/T/2020).

Study population

Married heterosexual women who were older than 18 years, not pregnant, and not menopausal were recruited as participants consecutively. We excluded women who were not sexually active and or at the time did not live with their spouse. In 2 weeks, 367 women participated in the survey from all around Indonesia. After evaluating the eligibility criteria and data cleaning, only 348 participants' data could be used in the analysis process. It met the minimum sample size (n = 345) required based on the Lemeshow formula (Lemeshow et al., 1991/1997) using the psychological distress rate reported by Xiong et al. (2020) as reference. The participants were then divided into four groups based on their compliance to the WFH policy, (1) Both couples (her and her spouse) work from home, (2) Only the wife works from home, (3) Only the husband works from home, and (4) Neither works from home.

General health questionnaire

General Health Questionnaire (GHQ) is a simple screening tool designed to detect current state mental distress in the primary care setting. The shortest version, 12-item version, is adopted as a screening tool in multiple countries, including Indonesia. The GHQ-12 questionnaire, which includes 12 questions, was used to assess mental health, whether the participants suffered from any psychological distress. GHQ-12 measured two latent variables, psychological distress and social function. Question number 2, 5, 6, 9, 10, and 11 refer to psychological distress, whereas the other questions refer to social dysfunction (Idaiani & Suhardi, 2006).

Every item in GHQ-12 must be answered, with the possible answers being “less than usual”, “no more than usual”, “rather more than usual”, or “much more than usual”. GHQ-12 can be scored at least by two types of methods, which are the bimodal scoring method (0-0-1-1) and the Likert scoring method (0-1-2-3). The scoring system used in this study is a bimodal GHQ scoring method (0-0-1-1 for positive statements). Using this scoring method means the answer "less than usual" and "no more than usual" were awarded 0 for questions stated in a positive statement. The answer "rather more than usual" and "much more than usual" were awarded1 point. Question number 2, 5, 6, 9, 10, and 11 are negatively phrased and scored in reverse (1-1-0-0). The total score ranges between 0 and 12, with the cutoff point for psychological distress being 7 or above (Idaiani & Suhardi, 2006). Validity and reliability test for the Indonesian version of GHQ-12 was first conducted in 2006. It was compared with the questionnaire with Symptom Checklist (SCL-90) as the gold standard. The Cronbach's α value for GHQ-12 is 0.841 for bimodal scoring (Anjara et al., 2020).

Reproductive health

The participants were asked how often they have sexual intercourse with their partner on average, before and after the WFH policy was enacted in Indonesia. The average SIF per week category was adapted from a study by Kontula and Haavio-Mannila (Kontula & Haavio-Mannila, 1995). It was divided into several groups: (0) no sexual intercourse at all, (1) once per month, (2) 2–3 times per month, (3) once per week, (4) 2–3 times per week, (5) 3–4 times per week, (6) 5–6 times per week, (7) once per day or more. The difference of SIF was categorized into several levels: (1) less, (2) same, and (3) more. Thus, the difference was analyzed as an ordinal scale. Contraception use during WFH was made into a Yes or No question. The participants were asked whether they had a normal menstrual pattern or abnormal menstrual pattern before and after the WFH policy was enacted. They were also asked about their desire to have children during the COVID pandemic period (the complete questionnaire is attached in Supplementary File 1).

Statistical analysis

SPSS version 25 (IBM Corp; Armonk, NY, USA) was used for statistical analysis. Kolmogorov‐Smirnov test was used to evaluate the distribution normality. Friedman and Kruskal Wallis H test were used to compare the results’ average and percentages between groups. Spearman's correlation test was used for testing relationships between variables. The regression analysis was used to identify any confounding factors. p value < .05 was considered statistically significant.

Results

In total, 348 women were enrolled in the study. The mean age of the study population and their spouses was 29.01 (SD = 4.99) and 31.75 (SD = 5.88) years old respectively. The mean couple's age difference was 3.05 (SD = 3.08) years, and the mean length of marriage was 3.79 (SD = 4.27) years. Most of the participants (74.4%, n = 259) have an undergraduate degree. The sociodemographic characteristics of the study participants are summarized in Table 1.

Table 1.

Sociodemographic Characteristics of Study Population.

Characteristics (n = 348)	Mean (SD)
Age (years)	29.01 (SD = 4.9)
Age of spouse (years)	31.75 (SD = 5.8)
Couple’s age difference (years)	3.05 (SD = 3.1)
Length of marriage (years)	3.79 (SD = 4.2)
No. of pregnancy	0.68 (SD = 1.0)
No. of parity	0.41 (SD = 0.7)
No. of abortion	0.30 (SD = 0.9)
No. of living children	0.42 (SD = 0.7)
Education Background
Primary school	4 (1.1%)
Middle school	4 (1.1%)
High school	48 (13.8%)
Undergraduate degree	259 (74.4%)
Graduate degree	33 (9.5%)
Household spending per month (Rupiah)
< Rp 1,300,000 per month	9 (2.6%)
Rp 1,300,000–Rp 1,830,000 per month	34 (9.8%)
Rp 1,830,001–Rp 2,500,000 per month	50 (14.4%)
Rp 2,500,001–Rp 3,790,000 per month	78 (22.4%)
> Rp 3,790,000 per month	177 (50.8%)
WFH status
Yes	269 (77.3%)
No	79 (22.7%)
WFH status of spouse
Yes	182 (52.3%)
No	166 (47.3%)
Couple WFH status
Both do WFH	148 (42.5%)
Only wife does WFH	121 (34.8%)
Only husband does WFH	34 (9.8%)
None do WFH	45 (12.9%)
Psychological status
Distress	167 (48.0%)
No distress	181 (52.0%)

Psychological distress (GHQ-12 score ≥ 7) occurred in 48.0% (n = 167) of participants. Based on WFH compliance, there were no significant differences between each group of WFH status when comparing psychological distress (χ²[3, N = 348] = 2.077, p = .56). Psychological distress occurrence in participants was found to show no statistically significant difference between those who experienced a decrease, same, or increased SIF before and during the pandemic (χ²[2, N = 348] = 2.077, p = .24) (Table 2).

Table 2.

Psychological Status and SIF.

Psychological Status	SIF			p Value
	Less (n = 126)	Same (n = 157)	More (n = 65)
Distress	68 (54.0%)	70 (44.6%)	29 (44.6%)	.24*
No distress	58 (46.0%)	87 (55.4%)	36 (55.4%)

*Chi-square test, χ²[2, N = 348] = 2.077, p = .24.

The median SIF before the WFH period was once per week (Mdn score = 4, Mean score = 3.38, SD = 1.1). Then it was found to be decreased to a median 2–3 times per month (Mdn score = 3, Mean score = 2.99, SD = 1.5) during the WFH period compared to the one month prior. A Wilcoxon signed-rank test indicated that the decrease was statistically significant, T = 5014, z = −5.598, p < .001, with effect size r = −.21. Kruskal–Wallis test was conducted to compare the difference of average SIF during WFH between WFH compliance groups. We found no significant differences between groups (H(3) = 5.34, p = .15). A logistics regression analysis was conducted to determine confounding factors that might affect the change of SIF. There were no sociodemographic variables (listed in Table 1, except WFH status and psychological distress) that appear to have affected psychological distress nor SIF changes (χ²(10) = 7.535, p < .674).

Contraception use was reported by 22.7% (n = 79) of the participants. Due to the pandemic, 43.7% (n = 152) of participants canceled their plans for having children (Table 3). 31.6% (n = 110) reported a change of menstrual pattern during WFH in pandemic period compared to their menstrual pattern before WFH in pandemic period. Psychological distress is a significant factor correlated with the change of menstrual pattern (r_s= .126, p = .018, N = 348) (Table 4).

Table 3.

Reproductive Health.

Reproductive health	Before WFH in pandemic period	During WFH in pandemic period	p value
Average SIF per week	3.38 (SD = 1.1)	2.99 (SD = 1.5)	<.001*
No sexual intercourse	n = 2 (0.6%)	n = 31 (8.9%)
Once per month	n = 14 (4%)	n = 25 (7.2%)
2–3 times per month	n = 68 (19.5%)	n = 74 (21.3%)
Once per week	n = 73 (21%)	n = 65 (18.7%)
2–3 times per week	n = 155 (44.5%)	n = 102 (29.3%)
3–4 times per week	n = 31 (8.9%)	n = 44 (12.6%)
5–6 times per week	n = 4 (1.1%)	n = 4 (1.1%)
Once per day or more	n = 1 (0.3%)	n = 3 (0.9%)
Modern contraception use
Yes		n = 79 (22.7%)
No		n = 269 (77.3%)
Menstrual pattern change
Yes		n = 110 (31.6%)
No		n = 238 (68.4%)
Cancel plan to have children
Yes		n = 152 (43.7%)
No		n = 184 (52.9%)
Did not plan		n = 12 (3.4%)

*Wilcoxon signed-rank test, T = 5014, z = −5.598, p < .001.

Table 4.

Psychological Status and Menstrual Pattern Change.

Psychological status	Menstrual pattern change		p Value
	Yes (n = 110)	No (n = 238)
Distress	63 (57.3%)	104 (43.7%)	.018*
No distress	47 (42.7%)	134 (56.3%)

*Spearman correlation test, r_s = −.126, p = .018, N = 348.

Discussion

Due to the COVID-19 pandemic, a significant change has impacted the global healthcare system. In Indonesia, a social restriction regulation was implemented including a governmental decision for employees to WFH for a certain amount of time (Djalante et al., 2020). WFH policies due to the pandemic have been known to have detrimental effects on mental health and reproductive health in affected people (Brooks et al., 2020; Riley et al., 2020).

WFH and mental health

We previously predicted that WFH contributing to more time spent in self-isolation at home would cause psychological distress in people affected. A review by Brooks et al. found that confinement, loss of usual routine, and reduced physical and social contact as the main stressors during quarantine (Brooks et al., 2020). A Spanish study on pregnant women also showed that confinement due to COVID-19 caused a decrease in quality of life and levels of physical activity (Biviá-Roig, 2020). However, since we found no significant differences in psychological distress levels between the WFH group and the non-WFH group, we believe that WFH or self-isolation have no additional impact on the level of psychological distress during the pandemic.

Previous studies have shown that the current COVID-19 pandemic has negative effects on mental health. The COVID-19 pandemic has also been shown to be associated with a higher prevalence of generalized anxiety disorder (GAD), depressive symptoms, and change in sleep patterns (Huang & Zhao, 2020). The study also discovered that the risk factor that strongly influences the psychological problems was spending too much time worrying about COVID-19. Another study in China showed a higher odd of experiencing anxiety or a combination of anxiety and depression in people with more frequent social media exposure toward news and information about COVID-19 (Gao et al., 2020). The studies on psychological problems due to COVID-19 were in line with previous studies on psychological problems during a major infectious disease outbreak, namely SARS (Su et al., 2007). The possible reasons for psychological problems may be due to fear or worry of being infected or fear that the pandemic would be hard to control.

We initially speculated that psychological distress in participants of this study might be correlated with the COVID-19 pandemic itself, or fear of the virus. Indeed, our study results showed a significant number of participants (n = 167, or 48.0% of the participants) experiencing psychological distress (GHQ-12 score ≥ 7). However, due to the limitations of our study design, we cannot determine or conclude the correlation between the existence of psychological distress and the COVID-19 pandemic.

WFH and reproductive health

In respect to the effect of WFH on reproductive health, we found that the average weekly SIF was significantly decreased during the WFH period compared to 1 month earlier. It was previously predicted that the WFH policy will cause an inevitable baby boom due to couples who are stuck at home together having a higher frequency of sexual intercourse (Matchan, 2020; Salisbury, 2020). Results from our study showed contradictory evidence toward this prediction. Our study results showed that the frequency of sexual intercourse during the pandemic significantly decreased, however, we also found that 52.9% (n = 184) of our study population did not change their desire to have children during the COVID-19 pandemic. Our study population also showed low use of modern contraception (only 22.7%, n = 79). The contradictory results on the risk factors for a baby boom (SIF, desire to have children, use of contraception) neither dispute nor confirms the prediction of a baby boom due to COVID-19 in Indonesia.

This result is in line with the findings of a study by Liu et al. following the earthquake in Wenchuan, China in 2009. Following the catastrophe, the study found a significant decrease in sexual intercourse frequency (SIF), sexual life satisfaction, and desire to have children following the earthquake (Liu et al., 2010). It might come from the fact that the current pandemic has caused psychological distress in the general population, which has been associated with a change in the frequency of sexual intercourse (Raisanen et al., 2018).

On the contrary, a recent study in Turkey found a significant increase in average weekly SIF during the pandemic compared with the 6–12 months prior (2.4 vs 1.9; p = .001) (Yuksel & Ozgor, 2020). The difference in findings may be caused by cultural and social norms differences between the two countries. As Rubin et al. stated in their study, cultural stereotype is one of the predictors for heterosexual women’s sexual desire (Rubin et al., 2019). In comparison, a study from Italy, which is a less conservative country than Turkey and Indonesia, found an increase in discontinuation of contraception use in single women, even though they continue to engage in sexual activity, causing a rise in the number of unplanned pregnancy (Caruso et al., 2020). Indonesians, in general, have a relatively religious and conservative culture. Most women in Indonesia are typically discouraged to explore sexual desire and pleasure. Thus, they are expected to control desire (Riyani & Parker, 2018). We believe this factor may partly affect the results of this study. Cultural factors must be taken into account in future studies focusing on sexual behavior.

Only 22.7% (n = 79) of participants in this study used contraception during WFH. In 2019 modern methods contraceptive prevalence rate (mCPR) among women in Indonesia was 43.5% (FP2020, 2019). Previous study found a significant number of women are less likely to access family planning services and to use contraception during a disaster (Kissinger et al., 2007).

In addition, 52.9% of our participants still plan to have children despite the circumstances. This finding is contradictory to another study in Turkey that found declined intention to get pregnant (Yuksel & Ozgor, 2020). However, the study populations of this study and Yuksel & Ozgor’s study were different, especially socioeconomic status. Yuksel & Ozgor postulated that the desire to have children in their study were decreased due to economic concerns and worry about the difficulty of access toward health facilities during the pandemic since most of their study population were from low to middle socioeconomic class. Conversely, the desire to have children in our population may not be decreased due to social security, since our study participants were mainly from middle to high socioeconomic status. Another study in Italy found a mixed result regarding the change of desire for parenthood during the COVID-19 pandemic (Micelli et al., 2020). The Micelli study found that fear of the impact of COVID-19 toward pregnancy and economic concerns were the main reasons their study population decided to interrupt plans to have children. On the contrary, they also found that 60% of the couples who were already attempting to have children decided to continue their pursuit, possibly because of fear of infertility in the future, since most of the population who were already involved in planning for children were from the older population (Micelli et al., 2020).

Psychological distress and reproductive health

Previous studies have described a correlation between psychological distress and frequency of sexual intercourse in females. However, these studies show contradictory results. A study of young women found higher levels of sexual activity in women with stress and depression compared to those without symptoms (Hall et al., 2014). Another study in North America reported that a higher level of stress resulted in a decrease in sexual desire (Hamilton & Meston, 2013). Another study by Liu et al found a decrease in SIF and a higher level of menstrual disorders after a natural disaster in China (Liu et al., 2010). However, in our study, we found a higher level of psychological distress levels in decreased SIF group (n = 68, 54.0%), although this difference is not statistically significant. This result showed that there is no correlation between psychological distress and reproductive behavior.

We found a change of menstrual pattern in 31.6% (n = 110) of females during WFH in pandemic period compared to their menstrual pattern before WFH was implemented. It is significantly correlated with psychological distress. The study in Turkey also found a higher frequency of menstrual abnormalities during the current pandemic (Yuksel & Ozgor, 2020). The same result was also found in a study following the Wenchuan earthquake, which found a higher incidence of abnormal menstruation in females with mental health disorders (Yuan et al., 2010).

Limitations

The limitations of this study were due to social restrictions; we were unable to conduct a face-to-face survey and had to rely on web-based method of gathering data. We were unable to find a larger number of participants also due to this reason. Recall bias due to the design of this study (cross-sectional) is also an unavoidable limitation. Further studies with a prospective design to avoid recall bias are necessary to accurately study the impact of WFH on reproductive health. In our study, we did not ask the reason behind no contraceptive use, which may be due to no access toward contraceptive or simply refusal to use contraceptive (due to religious or cultural reasons). In future studies, especially in Indonesia, it might be important to ask this to the participants.

We also did not ask for the history of mental health and/or psychological distress before the pandemic in the participants of this study, which excluded any possibility for us to analyze the correlation between psychological distress found on the participants of the study and the COVID-19 pandemic. This study mainly used self-reported questionnaires to measure psychiatric symptoms and did not make a clinical diagnosis. The gold standard for establishing psychiatric diagnosis involved a structured clinical interview and functional neuroimaging (Ho et al., 2020; Husain et al., 2020). Nevertheless, studies related to the mental health burden of COVID-19 are still scarce in Indonesia. More evidence-based research is necessary to further study the impact of the current pandemic on the mental health of the general population.

Furthermore, our study was conducted through online platform. This indirectly caused the participants of our study to be from people with middle to high socioeconomic class and high educational background, who have access to the internet and social media platform. Therefore, studies in the future should find a wider representation of the Indonesian demographics by being conducted not only through an online platform but also distributed offline.

Nevertheless, to the best of our knowledge, this is the first study to try to evaluate the impact of WFH policy on women’s health in Indonesia. We believe this study can add a new perspective regarding the impact of policies made during the pandemic, in particular on the mental and reproductive health of women in Indonesia.

Conclusion

This study showed a considerable number of women in Indonesia suffering from psychological distress and decreasing their SIF during the COVID-19 pandemic, regardless of their WFH policy compliance. It can be concluded that WFH does not aggravate the effect of the pandemic on married women's mental and reproductive health. However, more than half of the respondents of this study still wanted to have children and the majority of them did not use contraception. It is still unknown whether the baby boom following the pandemic will occur in Indonesia based on these findings.

Disclosure statement

The authors have no conflict of interest.