Short abstract
Concerns about vulnerability to COVID‐19 and vertical transmission of the disease led to increased incidence of psychological distress, depression, anxiety, and sleep disturbance among pregnant women in Lahore, Pakistan.
Keywords: Anxiety, COVID‐19, Edinburgh Postnatal Depression Scale, K10 scale, Perinatal depression, Pregnancy, Psychological impact
The substantial burden of the COVID‐19 pandemic has led to increased feelings of fear and uncertainty. The contagious nature and high mortality associated with the disease has caused psychological distress, depression, stress, and anxiety among the general population, including pregnant women. 1 , 2 The COVID‐19 pandemic affects pregnant women’s perceptions, appetite, psychosocial behavior, and sleep patterns, which in turn may impact the physical and cognitive development of their newborn babies. 3 This has resulted in myriad issues for overburdened health systems trying to provide appropriate medical and mental health care. 4 , 5 , 6 Pakistan, a low‐income country, has been slow to recognize maternal health conditions; therefore, these are unrecognized and undertreated. 7 , 8 The present study highlights socio‐demographic factors, psychological impact, levels of depression (no depression, possible depression, and maximum depression) and anxiety, lack of appetite, and sleep disturbances among pregnant women in Lahore, Pakistan, during the COVID‐19 pandemic.
A descriptive cross‐sectional study on pregnant women visiting the Outpatient Department (OPD) of Obstetrics and Gynecology, Sheikh Zayed Hospital, Lahore, was conducted from August 6–20, 2020; a consecutive sampling technique (non‐probability) was used. Pregnant women were included irrespective of their gestational period and parity, whereas pregnant women with psychiatric disorders and co‐morbidities were excluded from the study. A total of 600 pregnant women were selected for this study. Among the study group, 552 (92%) responded and were included for further analysis.
Psychological impact due to the COVID‐19 pandemic was measured using the Kessler‐10 scale (K‐10), 9 and depression and anxiety were measured using the Edinburgh Postnatal Depression Scale (EPDS). 10 Research data were evaluated using SPSS version 22.0 (IBM, Armonk, New York, USA).
Before commencement of the study, ethical approval was obtained from the relevant supervisor and Institutional Review Board of Shaikh Zayed Medical Complex, Lahore, Pakistan. Informed oral and written consent were obtained from all participants.
Of the 552 participants, 353 (64%) respondents displayed high levels of awareness of, and concerns about, the COVID‐19 pandemic (i.e. fears of carrying the virus, vertical transmission causing harm to fetuses, vulnerability), whereas 199 (36%) respondents showed lower levels of concern (Table 1). Table 2 shows socio‐demographic factors, psychological impact, depression and anxiety, lack of appetite, and sleep disturbances of pregnant women during the COVID‐19 pandemic, tabulated through frequency, percentage, mean and standard deviation, cross‐tabulation, and binary logistic regression (odds ratio and 95% confidence interval).
Table 1.
Perceptions of pregnant women toward the COVID‐19 pandemic (n=552).
| Perceptions of pregnant women toward the COVID‐19 pandemic (n=552) | Yes (%) | No (%) |
|---|---|---|
| Are you more vulnerable to contracting COVID‐19 than the general population? | 469 (85%) | 83 (15%) |
| Is vertical transmission of COVID‐19 to your fetus possible? | 351 (64%) | 201 (36%) |
| Can you contract COVID‐19 whilst visiting the hospital for your checkup? | 489 (89%) | 63 (11%) |
| Do you think elective cesarean section is a better option for delivery than vaginal delivery during the COVID‐19 pandemic? | 104 (19%) | 448 (81%) |
| Mean | 353 (64%) | 199 (36%) |
Table 2.
Factors associated with perceptions of pregnant women toward the COVID‐19 pandemic (n=552).
| Respondent’s factors associated with perceptions toward the COVID‐19 pandemic (N=552) | |||||
|---|---|---|---|---|---|
| Factors | Frequency (n=552) (%) | Perceptions of pregnant women toward the COVID‐19 pandemic (N=552) | Odds ratio 95% CI a | P value | |
|
Yes n=353 (64%) |
No n=199 (36%) |
||||
| Socio‐demographic factors | |||||
| Age of Women (years) | Mean ± Standard Deviation | 32 ± 7.3 | |||
| <25 | 123 (22%) | 39 (11%) | 84 (42%) | reference | 0.01* |
| 25‐35 | 173 (31%) | 113 (32%) | 60 (30%) | 1.60 (1.22–2.29) | |
| >35 | 256 (47%) | 201 (57%) | 55 (28%) | 1.97 (1.76–2.50) | |
| Education | |||||
| Illiterate | 87 (15%) | 7 (2%) | 80 (40%) | reference | 0.001* |
| Primary | 158 (29%) | 99 (28%) | 59 (30%) | 1.73 (1.42‐2.33) | |
| Secondary & higher secondary | 165 (30%) | 109 (31%) | 56 (28%) | 2.24 (1.88‐2.77) | |
| Graduate & post‐graduate | 142 (26%) | 138 (39%) | 4 (2%) | 2.45 (2.13‐ 3.01) | |
| Occupation | |||||
| Housewife | 206 (37%) | 95 (27%) | 111 (56%) | reference | |
| Private sector | 160 (29%) | 106 (30%) | 54 (27%) | 1.51 (1.10‐1.96) | 0.000* |
| Public sector | 186 (34%) | 152 (43%) | 34 (17%) | 1.89 (1.31‐2.32) | |
| Monthly household income | |||||
| <25 000 | 134 (24%) | 11 (3%) | 123 (62%) | reference | |
| 25 000–50 000 | 114 (21%) | 74 (21%) | 40 (20%) | 1.24 (1.04‐1.49) | |
| 51 000–75 000 | 111 (20%) | 81 (23%) | 30 (15%) | 1.87 (1.57‐2.22) | 0.03* |
| >75 000 | 193 (35%) | 187 (53%) | 6 (3%) | 3.04 (2.48‐3.70) | |
| Week of gestation | Mean ± Standard Deviation | 25.3 ± 10.4 | |||
| 1st trimester (1–13 weeks) | 204 (37%) | 67 (19%) | 137 (69%) | reference | 0.04* |
| 2nd trimester (14–26 weeks) | 162 (29%) | 116 (33%) | 46 (23%) | 1.56 (1.28‐1.67) | |
| 3rd trimester (27–40 weeks) | 186 (34%) | 170 (48%) | 16 (8%) | 2.03 (1.62‐2.47) | |
| No. of children | Mean ± Standard Deviation | 1.96 ± 1.04 | |||
| 0 | 148 (27%) | 7 (2%) | 141 (71%) | reference | |
| 1 | 170 (31%) | 138 (39%) | 32 (16%) | 0.71 (0.55‐ 1.49) | 0.34 |
| 2 or more | 234 (42%) | 208 (59%) | 26 (13%) | 1.11 (0.73‐ 1.56) | |
| Psychological impact | |||||
| Do you think that the COVID‐19 pandemic has affected your mental health? | |||||
| Yes | 199 (36%) | 190 (54%) | 9 (5%) | 2.61 (1.86‐3.31) | 0.002* |
| No | 353 (64%) | 163 (46%) | 190 (95%) | reference | |
| Level of disorder | |||||
| Likely to be well | 353 (64%) | 165 (47%) | 188 (94%) | reference | |
| Mild disorder | 151 (27.3%) | 142 (40%) | 9 (4%) | 2.64 (2.39 −3.15) | 0.003* |
| Moderate disorder | 40 (7.2%) | 39 (11%) | 1 (1%) | 2.43 (1.84 −2.57) | |
| Severe disorder | 8 (1.5%) | 7 (2%) | 1 (1%) | 1.61 (1.47 −2.38) | |
| Depression and anxiety | |||||
| Do you think the COVID‐19 pandemic has made you depressed or anxious? | |||||
| Yes | 215 (39%) | 199 (56.4%) | 16 (8%) | 2.87 (2.38‐3.64) | |
| No | 337 (61%) | 154 (43.6%) | 183 (92%) | reference | 0.01* |
| Level of depression | |||||
| Likely to be well | 337 (61%) | 159 (45%) | 178 (89.5%) | reference | |
| Possible depression | 182 (33%) | 164 (46.5%) | 18 (9%) | 2.83 (2.25‐3.57) | 0.02* |
| Maximum depression | 33 (6%) | 30 (8.5%) | 3 (1.5%) | 1.70 (1.34‐2.13) | |
| Lack of appetite and sleep disturbances | |||||
| Do you have a lack of appetite during the current pandemic? | |||||
| Yes | 182 (33%) | 180 (51%) | 2 (1%) | 0.99 (0.36‐1.34) | |
| No | 370 (67%) | 173 (49%) | 197 (99%) | reference | 0.28 |
| Do you have sleep disturbance during the current pandemic? | |||||
| Yes | 186 (34%) | 184 (52%) | 2 (1%) | 2.29 (1.72‐2.99) | |
| No | 366 (66%) | 169 (48%) | 197 (99%) | reference | 0.01* |
Reference category=1.
CI (Confidence Interval).
Statistically significant.
The K‐10 scale measures the psychological impact of the COVID‐19 pandemic on respondents (Table 2). The available answers for respondents were: none, a little, some, most, and all of the time. These answers were dichotomized into yes=1 (a little, some, most, and all of the time) and no=0 (none of the time). Thus, of the 552 participants in this study, 353 (64%) respondents experienced no effect on their mental health, had K‐10 scale scores lower than 20, and were likely to be well, whereas 199 (36%) pregnant women stated that the COVID‐19 pandemic had a large impact on their mental health. A total of 151 (27.3%) pregnant women displayed mild signs of psychological impact, with K‐10 scale scores between 20 and 24. Forty respondents (7.2%) had moderate signs of psychological impact, with K‐10 scale scores between 25 and 29, and eight (1.5%) respondents had severe signs of psychological impact, with K‐10 scale scores of 30 or higher.
Concerning the prevalence of depression and anxiety among the 552 respondents (Table 2), 337 (61%) pregnant women neither felt depressed nor anxious, had EPDS scores below 10, and were likely to be well. A total of 215 (39%) pregnant women stated that the COVID‐19 pandemic had caused them depression and anxiety, while 182 (33%) respondents were found to have possible depression, with EPDS scores of 10 or greater; 33 (6%) respondents scored 30 on the EPDS, indicating maximum depression.
The present study reveals pregnancy to be a determinant factor for negative perceptions of the COVID‐19 pandemic (e.g. being exposed, more vulnerable, and fearing vertical transmission or harm to the pregnant woman). The study also found associations between socio‐demographic factors (i.e. age, education, occupation, monthly income) and weeks of gestation, psychological impact, depression, anxiety, and sleep disturbances. Thus, despite the wealth of knowledge regarding the disease, the perceptions of pregnant women, social stigma, and discrimination from society have led to many challenges in dealing with the mental health of pregnant populations during the COVID‐19 pandemic. Educational programs should be designed to address pregnant women’s perceptions of the COVID‐19 pandemic in order to improve their mental wellbeing.
Author Contributions
AS contributed to the conception and design of the study, data collection, and writing of the manuscript. AJ contributed to the design of the study. SR contributed to data acquisition. RT contributed to analysis and interpretation of data. MI contributed to interpretation of the data and writing of the manuscript. MS finalized and revised the manuscript. All authors approved of the final version of the manuscript.
Conflicts of Interest
The authors have no conflicts of interest.
Acknowledgments
The authors thank Dr. Kalsoom Tariq and Dr. Tayyaba Muzaffar for their comments and advice on this paper.
References
- 1. Durankuş F, Aksu E. Effects of the COVID‐19 pandemic on anxiety and depressive symptoms in pregnant women: A preliminary study. J Matern Fetal Neonatal Med. 2020;15:1–7. [DOI] [PubMed] [Google Scholar]
- 2. Wu Y, Zhang C, Liu H, et al. Perinatal depressive and anxiety symptoms of pregnant women during the coronavirus disease 2019 outbreak in China. Am J Obstet Gynecol. 2020;223(2):240.e1–240.e9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Thapa SB, Mainali A, Schwank SE, Acharya G. Maternal mental health in the time of the COVID‐19 pandemic. Acta Obstet Gynecol Scand. 2020;99:817–818. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Xiang YT, Yang Y, Li W, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228–229. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID‐19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17:1729. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Gelaye B, Rondon M, Araya R, Williams M. Epidemiology of maternal depression, risk factors, and child outcomes in low‐income and middle‐income countries. Lancet Psychiatry. 2016;3:973–982. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Din YM, Munir SI, Razzaq SA, et al. Risk perception of COVID‐19 among pregnant females. Ann King Edward Med Univ. 2020;26:176–180. [Google Scholar]
- 9. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non‐specific psychological distress. Psychol Med. 2002;32(6):959–976. [DOI] [PubMed] [Google Scholar]
- 10. Wisner K, Parry BL, Piontek CM. Clinical practice: Postpartum depression. N Engl J Med. 2002;347(3):194–199. [DOI] [PubMed] [Google Scholar]