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. 2021 Jun 16;47(9):2990–3000. doi: 10.1111/jog.14877

Psychological stress among pregnant and puerperal women in Japan during the coronavirus disease 2019 pandemic

Soichiro Obata 1, Etsuko Miyagi 2,, Yasuo Haruyama 3, Takeshi Umazume 4, Gen Kobashi 3, Asuka Yoshimi 5, Akitoyo Hishimoto 5, Kentaro Kurasawa 2, Yukio Suzuki 2, Tomoaki Ikeda 6, Tadashi Kimura 7, Hideto Yamada 8
PMCID: PMC8447435  PMID: 34137109

Abstract

Aim

To evaluate psychological stress among pregnant and puerperal women in Japan during the coronavirus disease 2019 (COVID‐19) pandemic.

Methods

In this cross‐sectional study, we recruited pregnant women and puerperal women who delivered between January and September 2020 in Japan, using an online questionnaire. Participants were divided into low, middle, and high groups according to the degree of the epidemic in their region of residence. Related factors were analyzed using the chi‐squared test. The relationship between COVID‐19 epidemic regions and depression risks and anxiety using the Edinburgh Postnatal Depression Scale (EPDS) and Kessler 6 scale (K6) was evaluated using a univariate and multivariable logistic regression model.

Results

Overall, 7775 cases, including 4798 pregnant and 2977 puerperal women, were analyzed. The prevalence of high EPDS and K6 scores was significantly increased in pregnant women in the high than those in the low epidemic regions (EPDS: adjusted odds ratio [aOR] 1.453, 95% confidence interval [CI] 1.205–1.753; K6: aOR 1.601, 95% CI 1.338–1.918). There was no difference in EPDS score, but the prevalence of high K6 scores was significantly increased in puerperal women in the high than those in the low epidemic regions (aOR 1.342, 95% CI 1.066–1.690). Further, restriction on going to their hometown for delivery increased the prevalence of high EPDS scores among pregnant (aOR 1.663, 95% CI 1.296–2.133) and puerperal women (aOR 1.604, 95% CI 1.006–2.557).

Conclusions

Decreased support due to the COVID‐19 pandemic affected the psychological status of pregnant and puerperal women; hence, investing medical resources in their healthcare essential.

Keywords: anxiety, COVID‐19, depression, postpartum period, pregnancy

Introduction

A stressful event is one of the risk factors for depression.1, 2 Pregnancy and childbirth are both stressful events, and hence, pregnant and puerperal women are at high risk for depression.3 In 2020, the coronavirus disease 2019 (COVID‐19) pandemic occurred; the measures imposed to curb the spread of COVID‐19 forced people to change their lifestyle, putting them under tremendous stress. The COVID‐19 pandemic has already had a large‐scale, worldwide impact and has been defined as a “large‐scale disaster.” Previous reports have asserted that the COVID‐19 pandemic influences the psychological status of pregnant women.4, 5, 6, 7 However, the COVID‐19 pandemic situation in Japan differed from that found in other countries, in terms of the urgency of action of the medical system and the numbers of critically ill and total infected patients. In Japan, the COVID‐19 pandemic started in February 2020, and the first wave occurred in April 2020, with a peak of approximately 700 cases per day.8 The Japanese government declared a state of emergency in Tokyo, Osaka, and five prefectures on April 7, 2020. The declaration was extended to the entire nation of Japan on April 16, 2020, and rescinded by late May 2020. During the state of emergency, the government encouraged people to stay at home and discouraged travel between cities, although there was no legally binding force. Despite the emergency declaration, the increase in newly infected cases, which triggered the second wave in July and August, forced people to change their lifestyle to prevent infection. The peak of COVID‐19 cases in Japan in August at the time of the second wave was approximately 1600 cases per day.8 This number is far less than that of the 32 883–67 823 (minimum‐maximum during August 2020) in the United States during the same period.9 In view of the World Health Organization (WHO) regional classification, the numbers of COVID‐19 cases were far less in the Western Pacific region, including Japan, than in other regions of the world. The cumulative number of confirmed COVID‐19 cases on August 31st in the western Pacific region was 5395 (Japan had 601 cases). In contrast, 31 536, 84 650, 11 811, and 6411 cases were found in Europe, Southeast Asia, Eastern Mediterranean, and Africa, respectively. Lifestyle modifications due to the measures imposed to curb the spread of COVID‐19 may increase the burden on people, especially pregnant women, and on childcare during the pandemic. It is necessary to determine the problems people may face and take appropriate measures to improve the situation.

The purpose of this study was to analyze the psychological stress and anxiety in pregnant and puerperal women in Japan during the COVID‐19 pandemic in 2020. The results of this large‐scale questionnaire study on the psychological effects among pregnant and puerperal women in Japan during the pandemic may aid national and local governments, medical facilities, and healthcare professionals in formulating appropriate measures while considering this population in the future.

Methods

This cross‐sectional study used data from a voluntary questionnaire survey. The survey was conducted for women >20 years old or married minors >16 years old who were pregnant or those who had given birth in 2020. The survey commenced between September 1 and 30th, 2020, using a leaflet delivered at medical facilities and social networking sites such as Facebook, Twitter, Line, and others. An online questionnaire survey was also conducted during the same period. Consent to participate in the research was obtained from the potential participants before answering the questionnaire. We used one of the most secure online questionnaire sites, “SurveyMonkey™.” The information sent on the internet was encrypted and converted into data through a secure server without individual information.

Based on the data acquired from the online questionnaire survey, psychological stress and anxiety were assessed using the Edinburgh Postnatal Depression Scale (EPDS)10, 11 and the Kessler 6 scale (K6).12, 13 In addition, maternal characteristics and background, including whether they planned/had their delivery at the location of residence or went to their hometown, the prefecture of residence, educational and working background, and marital and household status, were obtained.

According to the number of COVID‐19 patients in the prefectures in Japan at the end of September,8 the participants were divided into low, middle, and high epidemic regions as follows: <500, ≥500 but <3000, and ≥3000 patients (Table 1). Sociodemographic factors, pregnant and puerperal‐related factors, COVID‐19 factors, and depression and anxiety were analyzed using the chi‐squared test among the three epidemic regions. To evaluate the accuracy of the responses to psychological stress in the current questionnaire, the correlation coefficient between EPDS and K6 scores was calculated. The relationship between the regions of COVID‐19 epidemic and depression and anxiety in pregnant and puerperal women was evaluated using univariate and multivariable logistic regression models. The multivariable analysis was adjusted for potential confounding factors, such as sociodemographic factors and pregnant or puerperal‐related factors.

Table 1.

Classification of the prefectures based on the number of COVID‐19 patients

Number of COVID‐19 patients Prefectures
≥3000 Tokyo, Osaka, Kanagawa, Aichi, Fukuoka, Saitama, Chiba, Hyogo, Okinawa, Hokkaido, Kyoto
≥500 but <3000 Ishikawa, Gunma, Ibaraki, Gifu, Kumamoto, Nara, Hiroshima, Shizuoka, Mie, Shiga, Tochigi, Toyama, Kagoshima, Nagano, Fukushima, Saga, Fukui, Wakayama, Nagasaki, Yamaguchi
<500 Yamanashi, Oita, Okayama, Shimane, Kochi, Ehime, Kagawa, Yamagata, Akita, Aomori, Tottori, Iwate

Abbreviation: COVID‐19, Coronavirus disease 2019.

All statistical analyses were performed using an assumed type I error rate of 0.05. Statistical analyses were performed using SPSS Statistics 26 for Windows (IBM Japan, Tokyo, Japan).

The present study was approved by the Institutional Ethics Committee of Yokohama City University (B 200800046), and all methods were performed in accordance with the Declaration of Helsinki. Consent to participate in the current study was obtained by confirmation from the participants at the start of the questionnaire responses.

Results

The flow chart of the cases included in the current study is presented in Figure 1. The number of participants was 9283. Cases with insufficient data were excluded, and 7775 cases (83.8%), including 4798 pregnant women and 2977 puerperal women, were analyzed.

Figure 1.

Figure 1

Flow chart for the selection of the participants. EPDS, Edinburgh Postnatal Depression Scale; Kessler 6 scale

The characteristics and background of the participants are shown in Tables 2 and 3. The number of pregnant women from the high, middle, and low epidemic regions was 2859 (59.6%), 1088 (22.7%), and 851 (17.7%), respectively. The number of puerperal women from the high, middle, and low epidemic regions was 1793 (60.2%), 701 (23.5%), and 483 (16.2%), respectively. Among both pregnant and puerperal women, most participants were found to be in the high epidemic regions.

Table 2.

Characteristics of pregnant women categorized by their residential prefectural COVID‐19 epidemic status at the end of September 2020 in Japan

Total Regions based on COVID‐19 epidemic status
(N = 4798) Low epidemic (n = 851, 17.7%) Middle epidemic (n = 1088, 22.7%) High epidemic (n = 2859, 59.6%)
n % n % n % n % p‐Valuea
Age group (years)
≤19 10 0.2 0 0.0 0 0.0 10 0.3 0.006
20–29 1405 29.3 288 33.8 319 29.3 798 27.9
30–39 3055 63.7 512 60.2 692 63.6 1851 64.7
40–49 324 6.8 49 5.8 76 7.0 199 7.0
Unknown 4 0.1 2 0.2 1 0.1 1 0.0
Weeks of gestation
1st trimester (<14 weeks) 644 13.4 110 12.9 150 13.8 384 13.4 0.979
2nd trimester (14–27 weeks) 1582 33.0 279 32.8 355 32.6 948 33.2
3rd trimester (≥28 weeks) 2572 53.6 462 54.3 583 53.6 1527 53.4
Number of children born before January 2020
0 3061 63.8 531 62.4 654 60.1 1876 65.6 0.015
1 1246 26.0 228 26.8 307 28.2 711 24.9
2 387 8.1 76 8.9 90 8.3 221 7.7
≥3 93 1.9 14 1.6 33 3.0 46 1.6
Unknown 11 0.2 2 0.2 4 0.4 5 0.2
Complications during pregnancyb
Threatened premature delivery 369 7.7 94 11.0 86 7.9 189 6.6 <0.001
Fetal disorder or fetal growth restriction 47 1.0 11 1.3 10 0.9 26 0.9 0.593
Placental malposition 84 1.8 11 1.3 23 2.1 50 1.7 0.392
Multiple pregnancy 69 1.4 17 2.0 19 1.7 33 1.2 0.120
Gestational hypertension 26 0.5 5 0.6 8 0.7 13 0.5 0.551
Gestational diabetes mellitus 208 4.3 41 4.8 45 4.1 122 4.3 0.763
Other 880 18.3 132 15.5 226 20.8 522 18.3 0.012
Delivery at hometown
No plan 3154 65.7 565 66.4 730 67.1 1859 65.0 0.107
Plan 1115 23.2 201 23.6 239 22.0 675 23.6
Refused by the facility 39 0.8 6 0.7 6 0.6 27 0.9
Gave up plan by due to advice of facility 31 0.6 2 0.2 8 0.7 21 0.7
Gave up plan by self 416 8.7 63 7.4 94 8.6 259 9.1
Unknown 43 0.9 14 1.6 11 1.0 18 0.6
Marital status
Married and live together 4539 94.6 800 94.0 1022 93.9 2717 95.0 0.104
Married and separated 139 2.9 25 2.9 36 3.3 78 2.7
Unmarried with a partner 55 1.1 12 1.4 10 0.9 33 1.2
Unmarried without a partner 50 1.0 7 0.8 17 1.6 26 0.9
Divorced 3 0.1 2 0.2 1 0.1 0 0.0
Bereaved 3 0.1 2 0.2 0 0.0 1 0.0
Unknown 9 0.2 3 0.4 2 0.2 4 0.1
Nationality
Japanese 4745 98.9 846 99.4 1078 99.1 2821 98.7 0.380
Other 40 0.8 3 0.4 8 0.7 29 1.0
Unknown 13 0.3 2 0.2 2 0.2 9 0.3
Education
Junior high school 80 1.7 16 1.9 18 1.7 46 1.6 <0.001
High school 713 14.9 162 19.0 183 16.8 368 12.9
College 794 16.5 164 19.3 194 17.8 436 15.3
Junior college 418 8.7 101 11.9 109 10.0 208 7.3
University 2411 50.3 366 43.0 497 45.7 1548 54.1
Graduate school (Masters) 309 6.4 34 4.0 72 6.6 203 7.1
Graduate school (Doctorate) 51 1.1 7 0.8 9 0.8 35 1.2
Unknown 22 0.5 1 0.1 6 0.6 15 0.5
Household income (JP¥)
<1 million 26 0.5 7 0.8 4 0.4 15 0.5 <0.001
1–3.99 million 553 11.5 141 16.6 150 13.8 262 9.2
4–6.99 million 1674 34.9 354 41.6 430 39.5 890 31.1
7–9.99 million 1234 25.7 185 21.7 247 22.7 802 28.1
≥10 million 869 18.1 68 8.0 143 13.1 658 23.0
Unknown 442 9.2 96 11.3 114 10.5 232 8.1
Current employment status
Full‐time 2034 42.4 322 37.8 417 38.3 1295 45.3 <0.001
Part‐time 439 9.1 96 11.3 104 9.6 239 8.4
On leave 880 18.3 152 17.9 181 16.6 547 19.1
Unemployed 65 1.4 15 1.8 20 1.8 30 1.0
Housewife or student 1342 28.0 253 29.7 359 33.0 730 25.5
Unknown 38 0.8 13 1.5 7 0.6 18 0.6
Edinburgh Postnatal Depression Scale scores
<9 3191 66.5 590 69.3 719 66.1 1882 65.8 0.091
≥9 but <13 905 18.9 156 18.3 219 20.1 530 18.5
≥13 702 14.6 105 12.3 150 13.8 447 15.6
Kessler 6 scale scores
<5 2887 60.2 556 65.3 660 60.7 1671 58.4 0.001
≥5 but <10 1279 26.7 215 25.3 276 25.4 788 27.6
≥10 632 13.2 80 9.4 152 14.0 400 14.0

Abbreviation: COVID‐19, Coronavirus disease 2019.

a

Chi‐squared test.

b

Multiple answers.

Table 3.

Characteristics of puerperal women characterized by the residential prefectural COVID‐19 epidemic status at the end of September in Japan

Total Regions of COVID‐19 epidemic status
(N = 2977) Low epidemic (n = 483, 16.2%) Middle epidemic (n = 701, 23.5%) High epidemic (n = 1793, 60.2%)
n % n % n % n % p‐Valuea
Age group (years)
≤19 4 0.1 1 0.2 1 0.1 2 0.1 0.001
20–29 896 30.1 180 37.3 238 34.0 478 26.7
30–39 1881 63.2 269 55.7 418 59.6 1194 66.6
40–49 195 6.6 33 6.8 44 6.3 118 6.6
Unknown 1 0.0 0 0.0 0 0.0 1 0.1
Days after childbirth
<42 (6 weeks) 684 23.0 117 24.2 158 22.5 409 22.8 0.822
42–183 (6 weeks to 6 months) 1825 61.3 293 60.7 424 60.5 1108 61.8
184–266 (6 months or more) 468 15.7 73 15.1 119 17.0 276 15.4
Number of children born before January 2020
0 1798 60.4 281 58.2 420 59.9 1097 61.2 0.180
1 931 31.3 151 31.3 212 30.2 568 31.7
2 200 6.7 44 9.1 53 7.6 103 5.7
≥3 46 1.5 7 1.4 15 2.1 24 1.3
Unknown 2 0.1 0 0.0 1 0.1 1 0.1
Complications during pregnancyb
Threatened premature delivery 410 13.8 83 17.2 105 15.0 222 12.4 0.014
Fetal disorder or fetal growth restriction 63 2.1 7 1.4 14 2.0 42 2.3 0.466
Placental malposition 102 3.4 18 3.7 20 2.9 64 3.6 0.625
Multiple pregnancy 28 0.9 3 0.6 6 0.9 19 1.1 0.652
Gestational hypertension 181 6.1 34 7.0 37 5.3 110 6.1 0.454
Gestational diabetes mellitus 179 6.0 29 6.0 34 4.9 116 6.5 0.311
Other 361 12.1 54 11.2 86 12.3 221 12.3 0.784
Delivery at hometown
No plan 2097 70.4 345 71.4 486 69.3 1266 70.6 0.687
Performed 718 24.1 112 23.2 171 24.4 435 24.3
Refused by the facility 16 0.5 5 1.0 2 0.3 9 0.5
Gave up plan due to advice of facility 9 0.3 0 0.0 3 0.4 6 0.3
Gave up plan by self 86 2.9 14 2.9 24 3.4 48 2.7
Unknown 51 1.7 7 1.4 15 2.1 29 1.6
Marital status
Married and live together 2874 96.5 462 95.7 675 96.3 1737 96.9 0.242
Married and separated 51 1.7 14 2.9 13 1.9 24 1.3
Unmarried with a partner 19 0.6 3 0.6 7 1.0 9 0.5
Unmarried without a partner 25 0.8 2 0.4 6 0.9 17 0.9
Divorce 6 0.2 2 0.4 0 0.0 4 0.2
Bereaved 2 0.1 0 0.0 0 0.0 2 0.1
Nationality
Japanese 2961 99.5 483 100.0 698 99.6 1780 99.3 0.318
Other 13 0.4 0 0.0 3 0.4 10 0.6
Unknown 3 0.1 0 0.0 0 0.0 3 0.2
Education
Junior high school 72 2.4 15 3.1 15 2.1 42 2.3 <0.001
High school 460 15.5 107 22.2 136 19.4 217 12.1
College 495 16.6 92 19.0 122 17.4 281 15.7
Junior college 250 8.4 53 11.0 64 9.1 133 7.4
University 1469 49.3 191 39.5 319 45.5 959 53.5
Graduate school (Masters) 201 6.8 21 4.3 38 5.4 142 7.9
Graduate school (Doctorate) 23 0.8 3 0.6 6 0.9 14 0.8
Unknown 7 0.2 1 0.2 1 0.1 5 0.3
Household income (JP¥)
<1 million 20 0.7 3 0.6 6 0.9 11 0.6
1–3.99 million 354 11.9 100 20.7 99 14.1 155 8.6 <0.001
4–6.99 million 1111 37.3 206 42.7 298 42.5 607 33.9
7–9.99 million 775 26.0 100 20.7 169 24.1 506 28.2
≥10 million 506 17.0 36 7.5 71 10.1 399 22.3
Unknown 211 7.1 38 7.9 58 8.3 115 6.4
Current employment status
Full‐time 665 22.3 100 20.7 125 17.8 440 24.5
Part‐time 113 3.8 21 4.3 31 4.4 61 3.4 <0.001
On leave 1150 38.6 184 38.1 254 36.2 712 39.7
Unemployed 57 1.9 9 1.9 10 1.4 38 2.1
Housewife or student 973 32.7 165 34.2 279 39.8 529 29.5
Unknown 19 0.6 4 0.8 2 0.3 13 0.7
Edinburgh Postnatal Depression Scale scores
<9 2110 70.9 351 72.7 495 70.6 1264 70.5
≥9 but <13 495 16.6 67 13.9 119 17.0 309 17.2 0.501
≥13 372 12.5 65 13.5 87 12.4 220 12.3
Kessler 6 scale scores
<5 1817 61.0 305 63.1 436 62.2 1076 60.0
≥5 but <10 745 25.0 116 24.0 160 22.8 469 26.2 0.371
≥10 415 13.9 62 12.8 105 15.0 248 13.8

Abbreviation: COVID‐19: Coronavirus disease 2019.

a

Chi‐squared test.

b

Multiple answers.

Moreover, age, educational level, household income, and the rate of full‐time working were high among the participants from the high epidemic regions. In contrast, the rate of cases requiring therapy for threatened premature delivery was high in the low epidemic regions.

Approximately 35% of pregnant women hoped to go to their hometown for delivery, but >30% were unable to do so due to the safety measures imposed to curb the COVID‐19 pandemic. In contrast, approximately 30% of puerperal women hoped to go to their hometown for the delivery, and 81.6% of them were able to do so.

In the univariate analysis of psychological stress, K6 scores tended to be higher among pregnant women in the high epidemic regions (p = 0.001). The correlation between the EPDS and K6 scores in the current questionnaire is shown in Supporting Information, Figure S1(a) and (b). Positive correlations were observed in both pregnant (r = 0.788) and puerperal women (r = 0.770).

Table 4 shows the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the relationship between the high score groups of EPDS and K6 and the COVID‐19 pandemic in pregnant and puerperal women with reference to the low epidemic region. In addition, the results of the logistic regression analysis adjusted for characteristics and backgrounds, which are shown in Tables 2 and 3 were also analyzed. Among pregnant women, participants with a high EPDS score were more commonly observed in the middle (aOR, 95% CI 1.266 [1.021–1.570]) and high (aOR, 95% CI 1.453 [1.205–1.753]) epidemic regions than in the low epidemic regions. Moreover, participants with high K6 scores were also more commonly observed in the middle (aOR, 95% CI 1.320 [1.074–1.623]) and high (aOR, 95% CI 1.601 [1.338–1.918]) epidemic regions than in the low epidemic regions.

Table 4.

Relationship between the residential prefectural COVID‐19 epidemic status and depression or anxiety among pregnant and puerperal women

Regions based on their COVID‐19 epidemic status
Low epidemic Middle epidemic p‐Valuea High epidemic p‐Valuea p for trend test
Pregnant women, n, % 732 17.1 956 22.4 2585 60.5
EPDS scores ≥9
Crude odds ratio, 95% CI Ref. 1.180 0.958–1.453 0.120 1.214 1.015–1.451 0.033 0.048
Adjusted odds ratio, 95% CI Ref. 1.266 1.021–1.570 0.032 1.453 1.205–1.753 <0.001 <0.001
K6 scores ≥5
Crude odds ratio, 95% CI Ref. 1.262 1.032–1.543 0.023 1.386 1.167–1.646 <0.001 <0.001
Adjusted odds ratio, 95% CI Ref. 1.320 1.074–1.623 0.008 1.601 1.338–1.918 <0.001 <0.001
Puerperal women, n, % 433 16.0 628 23.3 1639 60.7
EPDS scores ≥9
Crude odds ratio, 95% CI Ref. 1.077 0.821–1.412 0.593 1.071 0.846–1.355 0.568 0.634
Adjusted odds ratio, 95% CI Ref. 1.114 0.843–1.472 0.446 1.216 0.950–1.556 0.121 0.108
K6 scores ≥5
Crude odds ratio, 95% CI Ref. 1.040 0.807–1.342 0.761 1.176 0.944–1.465 0.148 0.093
Adjusted odds ratio, 95% CI Ref. 1.081 0.833–1.404 0.557 1.342 1.066–1.690 0.012 0.004

Abbreviations: 95% CI, 95% confidence Interval; COVID‐19, coronavirus disease 2019; EPDS, Edinburgh Postnatal Depression Scale; K6, Kessler 6 scale; Ref., Reference.

a

Using a univariate logistic model for the crude odds ratio and a multivariable logistic model after adjustment for age, weeks of gestation or days after childbirth, children, complications during pregnancy, homecoming delivery, marital status, nationality, education, household income, and employment status, but excluding unknown (n = 525 in pregnant women and n = 277 in puerperal women).

Data with a P‐value of less than 0.05 and a 95% confidence interval not crossing 1 are shown in bold.

In contrast to the pregnant women, there was no difference in the rate of high EPDS scores between the low, middle (aOR, 95% CI 1.114 [0.843–1.472]), and high epidemic (aOR, 95% CI 1.216 [0.950–1.556]) regions among puerperal women. Moreover, the rate of high K6 scores also did not differ in the low and middle epidemic regions (aOR, 95% CI 1.081 [0.833–1.404]), but was higher in the high epidemic regions (aOR, 95% CI 1.342 [1.066–1.690]).

Table 5 shows the results of the logistic regression analysis of the relationship between the prevalence of high EPDS and K6 scores and delivery at hometown. The aORs and 95% CIs were adjusted for maternal characteristics and background. Among pregnant women, high EPDS scores were observed more among those who could not go to their hometown for the delivery (refused by the hospital, gave up according to the obstetrician's instructions, or gave up voluntarily due to the COVID‐19 pandemic) than in those who could go to their hometown for the delivery (aOR, 95% CI 1.663 [1.296–2.133]). Similarly, higher K6 scores were observed in those who could not go to their hometown for the delivery (aOR, 95% CI 1.650 [1.294–2.103]), compared to those who could do so. Among puerperal women, high EPDS scores were observed in those who could not go to their hometown for the delivery (aOR, 95% CI 1.604 [1.006–2.557]); however, there was no difference in the prevalence of high K6 scores (aOR, 95% CI 1.392 [0.892–2.173]).

Table 5.

Relationship between delivery in the hometown and depression or anxiety among pregnant and puerperal women

Delivery at hometown
Plan Gave up p‐Valuea
Pregnant women, n, % 1007 69.4 445 30.6
EPDS scores ≥9
Crude odds ratio, 95% CI Ref. 1.542 1.223–1.942 <0.001
Adjusted odds ratio, 95% CI Ref. 1.663 1.296–2.133 <0.001
K6 scores ≥5
Crude odds ratio, 95% CI Ref. 1.554 1.240–1.947 <0.001
Adjusted odds ratio, 95% CI Ref. 1.650 1.294–2.103 <0.001
Performed Gave up p‐Valuea
Puerperal women, n, % 664 86.7 102 13.3
EPDS scores ≥9
Crude odds ratio, 95% CI Ref. 1.436 0.932–2.213 0.101
Adjusted odds ratio, 95% CI Ref. 1.604 1.006–2.557 0.047
K6 scores ≥5
Crude odds ratio, 95% CI Ref. 1.309 0.860–1.993 0.209
Adjusted odds ratio, 95% CI Ref. 1.392 0.892–2.173 0.145

Abbreviations: 95% CI, 95% confidence interval; COVID‐19, coronavirus disease 2019; EPDS, Edinburgh Postnatal Depression Scale; K6, Kessler 6 scale; Ref., Reference.

a

Using a univariate logistic model for the crude odds ratio and a multivariable logistic model after adjustment for age, weeks of gestation or days after childbirth, children, complications during pregnancy, marital status, COVID‐19 epidemic region, nationality, education, household income, and employment status, but excluding unknown (n = 149 in pregnant women and n = 63 in puerperal women).

Data with a P‐value of less than 0.05 and a 95% confidence interval not crossing 1 are shown in bold.

Discussion

Due to the COVID‐19 pandemic, psychological stress found in pregnant and puerperal women in Japan was higher than that previously reported.14 Psychological stress tended to be higher in the regions with a high prevalence of the disease than in those with a low prevalence of the disease. In addition, decreased support from the partner and family due to the pandemic affected the psychological status of pregnant and puerperal women. Therefore, it is important to build a support system for this population.

In a large study, which included 92 796 puerperal women before the COVID‐19 pandemic,14 only 12 819 women (17.8%) had a high EPDS score (≥9), and only 26 308 women (28.4%) had a high K6 score (score of 5 or higher). In the current study, the rates of prevalence of high EPDS and K6 scores among pregnant women were 33.5% and 39.9%, respectively and in puerperal women were 29.1% and 38.9%, respectively. These rates are higher than that reported in a previous study,14 indicating that the psychological stress in pregnant and puerperal women in Japan during the COVID‐19 pandemic was higher than that before the pandemic. This tendency must be considered immediately as stressful events are risk factors for postpartum depression.1 Zanardo et al.7 reported that the EPDS score was significantly higher after the COVID‐19 pandemic, and the rate of patients with high EPDS scores tended to be higher. Wu et al.4 also reported a significant increase in a high EPDS score after the COVID‐19 pandemic in a larger study (26.0% vs. 29.6%, p = 0.02). The results of the current study are consistent with those of previous studies and suggest that the COVID‐19 pandemic increases psychological stress. However, unlike in other countries where there are strong social restrictions and lockdowns, the Japanese government only recommended people refrain from moving across prefectures, and the restrictions were relatively lax without legal penalties. In addition, the total numbers of COVID‐19 cases were low when compared to other countries,9 and the medical system has not been overburdened so far in Japan. Therefore, the situation is quite different from other countries where previous reports have been published. The COVID‐19 pandemic is still not under control, and the number of patients is increasing. The epidemic situation in Japan could worsen in the future, as in the case of other countries, and the psychological stress in pregnant and puerperal women could be higher.

To the best of our knowledge, this is the first study to compare psychological stress in pregnant and puerperal women according to the degree of the COVID‐19 pandemic on a large scale. The results showed that psychological stress increased more in the middle and high epidemic regions than in the low epidemic regions during the same period. This suggests that if the COVID‐19 pandemic becomes more severe, the number of pregnant and puerperal women suffering from anxiety and depression will increase. Therefore, as the COVID‐19 pandemic does not appear to be under control, it is necessary to build an advanced and efficient system for psychological stress care for pregnant and puerperal women and increase the availability of medical resources.

Racine et al.15 asserted the importance of partner and family support for psychological stress during pregnancy and the postpartum period. Going to their hometown for the delivery is a unique culture in Japan, in which a pregnant woman returns to her hometown, where her parents live, to deliver her baby to get support from her family during pregnancy and the postpartum period. The Tokyo Midwives Association conducted an online survey of 2872 pregnant women in Tokyo during the outbreak of COVID‐19 in April.16 It was suggested that being advised to refrain from going to other prefectures from Tokyo for the delivery at hometown might increase psychological stress among pregnant women.16 Consistent with this report, the results of the current study indicated that restrictions on visiting their hometown for the delivery increased psychological stress in pregnant and puerperal women.

In Japan, it is estimated that restrictions on delivery at hometown could lead to insufficient support for pregnancy and puerperal women. The present study showed that psychological stress was higher in pregnant women who could not go to their hometown for the delivery due to the COVID‐19 pandemic than in pregnant women who could go to their hometown for the delivery as planned. In this study, more than 30% of pregnant and puerperal women wanted to go to their hometown for the delivery. However, 30% of the pregnant women who hoped to go to their hometown for the delivery could not do so because of the COVID‐19 pandemic; these groups were more stressed than those who planned to come to their hometown for the delivery as scheduled. In contrast, no significant difference was observed among the puerperal women, but only 18.4% of them were unable to return to their hometown for the delivery. This may be because going to their hometown for the delivery was more widely restricted at the time of the current survey than at the beginning of the COVID‐19 pandemic. Therefore, as the COVID‐19 pandemic continues, it is expected that the number of puerperal women who cannot go to their hometown for delivery will increase, and a significant difference may emerge in psychological stress in the future.

There are several limitations of the present study. Since this was a cross‐sectional study, we were unable to evaluate changes in psychological stress before and after the COVID‐19 pandemic among the same participants. The epidemic regions are a relative definition, as COVID‐19 is currently pandemic, and its morbidity changes daily. Further, we could not analyze the difference between the city center and the suburbs in the same prefectures. In addition, the accuracy of each response cannot be guaranteed because the survey was based on questionnaires that were not administered face‐to‐face or referred from medical records. Further, most of the participants were from a high epidemic region, and the possibility of a selection bias could not be ruled out. However, this was a cross‐sectional study of a large scale that has not been reported before. Moreover, because there was a positive correlation between the EPDS and K6 scores (Figure S1(a) and (b)), the accuracy of the data could be sufficiently guaranteed for analysis. Therefore, the findings obtained from this study are significant and reliable.

In summary, we proved that the COVID‐19 pandemic affected psychological status of pregnant and puerperal women. The infection status of the place of residence and the restrictions on traditional delivery at their hometown because of the COVID‐19 pandemic led to insufficient support for pregnant and puerperal women in Japan. These were significant risk factors for increased psychological stress. As the COVID‐19 pandemic spreads and continues, psychological stress in this population is likely to increase. Therefore, building an appropriate medical care system and investing medical resources in mental healthcare for pregnant and puerperal women is an urgent task that needs to be addressed.

Conflict of interest

The authors declare no conflict of interest.

Author contributions

Soichiro Obata wrote the initial draft of the manuscript as the first author and contributed to creating the questionnaire and finalizing the manuscript. Etsuko Miyagi designed the study protocol and contributed to finalizing the manuscript. Yasuo Haruyama contributed to the statistical analysis. Takeshi Umazume and Yukio Suzuki contributed to creating the questionnaire. Gen Kobashi, Asuka Yoshimi, Akitoyo Hishimoto, and Kentaro Kurasawa contributed to the review of the questionnaire. Tomoaki Ikeda, Tadashi Kimura, and Hideto Yamada contributed to supervising the protocol, and reviewed and approved the manuscript. Hideto Yamada obtained the grant. All authors contributed to the interpretation of the results.

Supporting information

Figure S1 Correlation between EPDS and K6 score in the (a) pregnant women (n = 4798), and (b) puerperal women (n = 2977)

Acknowledgments

This work was supported by the Ministry of Health, Labour and Welfare of Japan (Grant Number 20CA2033) and the Subcommittee on Perinatal Infection of the Committee on the Perinatal Period of Japan Society of Obstetrics and Gynecology. This work was collaborating study with Japan Society Obstetrics and Gynecology Perinatology Committee. The authors thank Prof. Shigeru Saito, Prof. Satoshi Hayakawa, Prof. Kei Kawana, Assoc. prof. Satoru Ikenoue, Prof. Masayo Takada, and Prof. Ichiro Morioka for the helpful advice and cooperation for the recruitment of study participants. The authors would like to thank Editage (www.editage.com) for English language editing.

Data availability statement

Research data are not shared.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S1 Correlation between EPDS and K6 score in the (a) pregnant women (n = 4798), and (b) puerperal women (n = 2977)

Data Availability Statement

Research data are not shared.


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