The Covid 19 outbreak: Maternal Mental Health and Associated Factors

Abstract

Objective

Evaluation of the mental health of pregnant women during the early and peak stages of the Covid-19 outbreak

Design

Online survey

Participants

Pregnant women over the age of 18 years with no mental disorder during the pre-pregnancy period (N = 729).

Measurements and Findings

Mental disorders were assessed using the “Depression Anxiety Stress Scale” and social support was determined using the “Multidimensional Perceived Social Support Scale.” Pregnant women had moderate levels of anxiety and depression and mild levels of stress. Anxiety, depression, and stress of moderate or high severity was reported in 62.2%, 44.6%, and 32.2% of the women, respectively. Pregnant women who lost their jobs during the pandemic period showed a 3-fold increase in the risk of anxiety, a 6-fold increase in the risk of depression, and a 4.8-fold increase in the risk of stress. An increase in the perception of social support has protective effects against all three mental disorders during pregnancy. In pregnant women with at least one obstetric risk, the risk of antenatal anxiety is 2 times higher than that in women with no risk. Similarly, women with a chronic physical illness before pregnancy have a higher risk of anxiety during pregnancy than healthy women. Financial strain has predictive value for anxiety and depression, and advanced age is a predictor for depression.

Key Conclusions

The incidence of mental disorders in pregnant women during the pandemic period was much higher than that during the pre-pandemic period. The high frequency of antenatal mental disorders can lead to an increase in the frequency of obstetric and maternal complications in the short and long term.

Implications for practice

Early detection of inadequate social support and economic difficulties of pregnant women during the pandemic period is recommended for protecting their mental health. Pregnant women should have easy access to psychosocial support, and they should be provided obstetric counseling during the pandemic conditions.

Introduction

Since early 2020, one of the most important health-related problems across the world has been the outbreak of the novel coronavirus (Covid-19). To prevent an increase in the number of patients with Covid-19 infection, since the beginning of the pandemic, Turkey imposed various and comprehensive measures, including city quarantines, travel bans, curfews, home isolations, restrictions in crowded public places, closure of schools, and implementing alternate working arrangements. The number and extent of these measures are increased or decreased depending on the trend of the number of cases in Turkey. The concerns surrounding the epidemic and implementation of the measures for preventing the infection have imposed sudden restrictions and have disrupted the daily routines of people during the pre-pandemic times. Additionally, various organizations have warned of the potential increase in mental disorders since the beginning of the epidemic (American Psychological Association, 2020; Black Dog Institute, 2020; World Health Organization, 2020a). One of the earliest studies conducted in China, which was the origin of the epidemic started, showed the importance of this warning (Wang et al., 2020). The relationship between social isolation, which is one of the effective methods of prevention of pandemics, and depression is well known (Matthews et al., 2016); in addition, individuals in social isolation showed symptoms of anger and anxiety several months after isolation (Cameron et al., 2020).

Pregnancy is a period of unique physiological and psychosocial changes. In addition, it is a stressful period with obvious and potential challenges. Therefore, women are more vulnerable to mental problems during pregnancy, and the frequency of mental disorders increases during pregnancy. The most common mental disorders in the antenatal period are depression and anxiety (Alipour et al., 2012; Biaggi et al., 2016; World Health Organization, 2008). A stressful event increases the risk of expectant mothers developing psychological difficulties or mental disorders (Biaggi et al., 2016). In this context, the Covid-19 outbreak is a global disaster that can increase this risk because of both the fear of developing the infection and the measures implemented to curb the pandemic. Pregnant women may be stressed because of the fear of contracting the infection, the fear of passing on the infection to their baby, and the concerns regarding the potential side effects on the fetus of antiseptics commonly used during the epidemic. Further, the fear of infection may lead to an overuse of antiseptics and detergents containing substances such as alcohol and hydrochloric acid, and they may avoid antenatal visits because of the fear of contamination. With a change in hospital policies and procedures to reduce transmission, the schedules of the women's antenatal visits may be impacted and may result in changes in their delivery plans (Rashidi Fakari and Simbar, 2020). Lack of control over decisions about childbirth is traumatic for women (Patterson et al., 2019). Further, absence of family support during pregnancy and childbirth is difficult to deal with for women (Brooks et al., 2020). In addition, during the postpartum period, they may experience problems with breastfeeding because of the concern of infection (Rashidi Fakari and Simbar, 2020). Other factors responsible for affecting mental health include changes in working life, decreased household income, and social isolation (Biaggi et al., 2016; Cameron et al., 2020). The newly coined term infodemic refers to direct access to a large amount of content regarding the epidemic on the Internet and social media (World Health Organization, 2020b; Zarocostas, 2020). This content includes both true and false information, and some studies indicate that fake news and false information can spread faster and wider than factual news (Vosoughi et al., 2018). Therefore, continuous and intense exposure to news about the epidemic on the Internet and social media can also increase the anxiety in mothers.

Antenatal mental disorders are of great importance due to the potential maternal and fetal/childhood complications. Maternal depression has been associated with low birth weight, preterm delivery, and other adverse pregnancy outcomes. Eating disorders and antenatal stress can lead to abnormalities in fetal birth weight (Gold and Marcus, 2008). Thornton et al. (2010) showed that the frequency of "any obstetric complications" in labor and delivery in women diagnosed with mental illness is higher than that in the general population. The strongest risk factor for developing psychopathological disorders in the postnatal period is the presence of psychopathological disorders during the prenatal period. Moreover, antenatal mental disorders are associated with postpartum emotional abuse and parental neglect, and they increase the risk of development of psychopathological disorders in children. Additionally, psychopathological disorders in children may be passed on to their next generation in the future (Aktar et al., 2019).

Although considerable literature regarding the Covid-19 pandemic and pandemics in the past is available, the number of studies on the effects of these pandemics on antenatal mental health is limited. In this study, we aimed to identify the rates of prevalence of maternal depression, anxiety, and stress during the mandatory social isolation period and to investigate factors affecting the risk for clinically significant symptoms.

Methods

This cross-sectional study was conducted online. Questions of the study were uploaded to “Google Forms,” and announcements were made for the study on a social media page called "Sağlıklı Yaşıyoruz" ("We live in healthy" in English). This social media page posts about healthy lifestyle recommendations based on current scientific evidence. The content on this page was controlled by 19 physicians belonging to different branches. The three main reasons for choosing this method for reaching out to women were as follows: 1) Providing access to pregnant women who cannot leave their homes because of the epidemic 2) Providing access to women from different cities, and 3) Increasing the reach by using a social media platform with a high number of followers (about 1 million on Instagram, about 400 thousand on Facebook) and is managed by healthcare professionals.

The survey was filled out online from 5/6/2020-12/6/2020. All pregnant women between the ages of 18 and 45 and at any gestational week were included in the study. Women submitting an incomplete questionnaire, women with inconsistent answers in their questionnaires (inconsistent answers related to obstetric and gynecological characteristics such as last date of menstruation), and women who indicated that they had a psychiatric disorder in the past were excluded. Three different forms of data collection tools were used in the study.

Study form: This form was developed by the investigators, and it included questions about the baseline characteristics, overall health status of the women, their knowledge about the pandemic, and presence of obstetric risk factors. Four of the questions were open-ended. The open-ended questions required women to write down the actions and situations they perceived as challenging and supporting during the epidemic period, and the reasons that caused anxiety regarding their pregnancy. The answers were collected under the main headings they are related to (economic, social, birth, etc). The presence of systemic diseases such as diabetes, hypertension, asthma, and thyroid dysfunction in women during the pre-pregnancy period were classified as"presence of chronic disease" variable with "present" and "none" subgroups. The term "term pregnancy" in the study refers to pregnancies at and above 37 weeks of gestation. The average length of time women remained isolated at home during the epidemic period was evaluated under the "duration at home isolation" variable.

Depression anxiety stress scale (DASS): The DASS is a Likert type scale of 4 with 3 sub-dimensions of 7 questions each, used for the detection of depression, anxiety, and stress levels (Lovibond and Lovibond, 1995). High scores indicate a related mental disorder. The DASS has cut-off scores, indicating mild, moderate, and severe levels of the related disorder.

Multidimensional scale of perceived social support (MSPSS): The MSPSS is a scale that subjectively evaluates the adequacy of social support from three different sources (family, friend, and significant others). A high score on the scale indicates a high level of perceived social support. Per recommendation from a previous study, women in this study were divided into low (12-35), medium (36-60), and high (61-84) social support groups (Zimet et al., 1990)

The study was approved by the Ethics Committee of a university (date: 4/6/2020, protocol no: 50). The online survey was preceded by a written disclosure section about the study. The participants were transitioned to the survey once approval was obtained. The data were collected anonymously.

To determine the statistical significance of the results, the degree statistical significance was set as p = 0.05. Results were reported as means, medians, or as values (%). Normality of distribution was tested using the Kolmogorov–Smirnov normality test. On the basis of the type of variables and the pattern of distribution, we performed the Mann–Whitney U-test, independent sample t test, Kruskal Wallis test, and one-way analysis of variance (ANOVA). Multivariate binomial logistic regression was performed to examine whether binary categorical and continuous variables affect maternal depression and anxiety risk.

Findings

A total of 989 women participated in the study. Women who submitted an incomplete questionnaire (n = 166), women with inconsistent answers in their questionnaires (n = 5), and women with a previous psychiatric disorder (n = 89) were excluded.

Sociodemographic and obstetric characteristics of women are shown in Table 1 . Women from 56 different cities participated in the study. The percentage of women of advanced maternal age (≥35 years) was 17.8%. Approximately half of the women were in their second trimester. Term pregnancy was reported in 6.2% of the women. About half of the women were nulliparous.

Table 1.

Sociodemographic and obstetric characteristics of women.

	% (n)	Mean±SD
City
İstanbul	32.7% (237)
Ankara	16.2% (117)
Bursa	7.9% (57)
İzmir	6.7% (56)
Others	35.5% (257)
Age		30.4 ± 4.3
Body mass index (kg/m2)		24.81 ± 4.1
Gestation
1st trimester	22.1% (160)
2nd trimester	48.8% (353)
3rd trimester	29.1% (211)
Parity
Nulliparous	46.1% (334)
Primiparous	29% (210)
Multiparous	28.8% (180)
Number of family members (except herself)
≤3	73.6% (533)
>3	26.4% (191)
Economic condition
Poor	9.8% (71)
Moderate	49.2% (356)
Good	41 (297)
Employment
Housewife	75.3% (545)
Employee	24.7% (179)

SD: Standard deviation.

Diabetes, hypertension, and thyroid disorders were the three most common chronic diseases reported in women in the pre-pregnancy period. At least one obstetric risk was reported in 20% of the women. About one-third of women who had not had antenatal visit for more than two months were term pregnancies. Ninety-five (13%) women had body mass index of ≥30 kg / m² (Table 2 ).

Table 2.

Obstetric and general risk factors of women

Risk factors	% (n)
Smoking
Active smoker	10.6% (77)
Pasive smoker	14.8% (107)
Chronic physical disease	24.5% (177)
Obstetric risks (multiple choice question)
Vaginal bleeding during this pregnancy	11.2% (81)
Rh isoimmunization	7.3% (53)
Assisted reproductive technology	10.6% (77)
Multiple pregnancy	2.3% (17)
Gestatitonal diabetes	5.5% (40)
Pregnancy induced hypertension	2.8% (20)
History of hypertension/diabetes in previous pregnancies	4.7% (34)
Placental and / or amniotic fluid pathologies	2.9% (21)
Intrauterine fetal death in previous pregnancies	3.6% (26)
History of preterm labor	4.6% (33)
Two or more uterine incision	3.9% (28)
Fetal anomaly in previous pregnancies	0.7% (5)
Last antenatal visit
Last month	42.5% (308)
Between 1-2 months	30.2% (219)
More than 2 months	21.5% (156)
Never	5.7% (41)
Vitamin and mineral deficiency
Iron	36.7% (266)
B12	18.6% (135)
Vitamin D	33.1% (240)

Findings related to daily life in home isolation and curfews, which were extensively implemented in the early phase of the Covid-19 epidemic, are shown in Table 3 . The percentage of women who worked before the outbreak of the Covid-19 pandemic but were placed on paid leave during the outbreak was 6.5%, and that of women who experienced job loss was 0.8%.

Table 3.

Characteristics of home-isolation period

Chracteristic	Mean±SD / % (n)
Duration of home-isolation period (weeks)	3.55 ± 1.99
The possibility to reach a healthcare professional remotely in an emergency condition
No	47.7% (345)
Obstetrician	38% (275)
My doctor's secretary	7.3% (53)
My health worker friend/relative	3.7% (27)
Family physician/midwife	3.3% (24)
Daily food consumption
less than before	18.6% (135)
almost same	56.4% (408)
more than before	25% (181)
Most reliable source of information about the pandemic
Ministry of health	64.9% (470)
Social media	13.5% (98)
Other resources on the internet	12.6% (91)
News and health-related programs on television	9% (65)
Mode of work (for working women)
remotely	71.5% (128)
few days a week	12.8% (23)
every day	15.6% (28)
Regular weight monitoring	20.9% (151)
Regular blood pressure monitoring	5.9% (43)

SD: standard derivation.

Low levels of perceived social support were reported in 20.9% of women. According to the DASS 21 scores, the women had moderate anxiety, moderate depression, and mild stress. (Table 4 ).

Table 4.

Findings regarding perceived social support and mental disorders

MSPSS scores
Family	16 ± 5.5
Friend	16.5 ± 4.9
Significant others	16.5 ± 5.15
Total	48.9 ± 14.9
DASS 21 scores
Depression	13.19 ± 8.74
Normal	33.7% (244)
Mild	21.7% (157)
Moderate	25.7% (186)
Severe	9.8% (71)
Extremely severe	9.1% (66)
Anxiety	12.5 ± 7.82
Normal	29.7% (215)
Mild	8.1% (59)
Moderate	19.2% (139)
Severe	28.5% (206)
Extremely severe	14.5% (105)
Stress	16.01 ± 8.82
Normal	47.5% (344)
Mild	20.3% (147)
Moderate	15.3% (111)
Severe	12.2% (88)
Extremely severe	4.7% (34)

MSPSS: Multidimensional Scale of Perceived Social Support. DASS: depression anxiety, stress scale.

Situations and actions that women perceive as challenging and supportive during curfew and home isolation period, and the factors causing concerns about their pregnancy are shown in Table 5 . About half of the women wished that their pregnancy would end healthily as soon as possible. Cesarean delivery was the preferred method of delivery of 53% of women.

Table 5.

Situations and actions that women perceive as challenging and supportive during curfew and home isolation period, and the factors causing concerns about their pregnancy

The most frequent situations and actions that women perceive as "challenging"
-The top 3 answers to a multiple choice question-Economic strain (23.3%), News about the pandemic (19.3%), Children (16.2%)-General headings according to the content of the answers given to the open-ended question-Economic strain, Fear of contamination, Keeping children at home, Chemicals, Extra cleaning, Shopping, Being away from relatives / friends, Inactivity, Restriction of freedom, Provide protective equipment.
The most frequent situations and actions that women perceive as "comfortable"
-The top 3 answers to a multiple choice question-Distance education, Information, consultancy support from obstetricians and midwives (49.3%), Psychological support (46.4%), Economic support (36.3%)-General headings according to the content of the answers given to the open-ended question-Communication with other pregnant women, Educational tv programs, Antenatal follow-up at home and home birth, Isolated room at home, Isolated antenatal follow-up centers, Information about safety and precautions, Freedom of movement, Safe transport to the hospital, Administrative paid leave, Awareness of people and full compliance with the rules, Isolated centers for blood tests, Walking and sports opportunities in parks, beaches and green areas, Isolation with loved ones, Remote psychological support, Curfew until the pandemic is over, Economic support
Causes of concern about pregnancy
- According to the answers to the open-ended question-Difficulties in antenatal follow-up, Changes in birth plans and uncertainty, Concern for infection, Difficulty in accessing obstetricians, Fear of loneliness during pregnancy and childbirth, Difficulty in accessing protective equipment, Uncertainty in the pandemic

Anxiety and stress scores were significantly higher in women who were active smokers than those who were non-smokers (p < 0.005, p < 0.005, respectively). The scores of anxiety, depression, and stress were higher in single/widowed women than in married women (p = 0.028, p = 0.024, p = 0.02 respectively), and these scores were higher in women who smoked passively than in those who were not exposed to cigarette smoke (p < 0.005, p < 0.005, and p < 0.005). The average anxiety and stress scores were significantly higher in women in their third trimester than in those in their second trimester (p = 0.023 and p = 0.007, respectively). The average anxiety scores were significantly higher in multiparous women than in primiparous and nulliparous women (p < 0.005 and p < 0.005 respectively). In addition, the mean stress scores were higher in multiparous women than in nulliparous women (p = 0.035).

A moderately negative correlation was observed between the MSPSS score and anxiety, depression, and stress scores (p < 0.005).

Binominal logistic regression analyses were performed to evaluate the factors affecting the presence of moderate or higher anxiety, depression, and stress in pregnant women (Table 6 ). The logistic regression models were statistically significant. Five out of 10 predictor variables were statistically significant for the presence of moderate/high levels of anxiety and depression, and two for the presence of moderate/high levels of stress. The risk of moderate/high level anxiety was 3 times higher in women who experienced job loss than those who did not. This risk was 2 times higher in women with at least one obstetric risk than in women without any obstetric risk. The risk of moderate or high level of depression was 2.2 times higher in women with poor economic status than in women with an adequate economic status. The risk of moderate and high level of depression was 6 times higher in women who lost their jobs during the pandemic than in those who did not lose their jobs and who did not work. In addition, increased age was associated with an increased risk for development of moderate/high level of depression. Similar to the risk of anxiety and depression, the risk of moderate to high stress was 4.8 times higher in women who experienced job loss than in women without job loss and who did not work. Increased MSPSS scores were associated with a reduction in the likelihood of moderate/high anxiety, depression, and stress in pregnant women (Table 6).

Table 6.

Logistic regression analyses for moderate to severe mental disorders risk in pregnant women.

	Anxiety				Depression				Stress
	P value	Odds ratio	95% Cl for OR		P value	Odds ratio	95% Cl for OR		P value	Odds ratio	95% Cl for OR
			Lower	Upper			Lower	Upper			Lower	Upper
Age	0.667	10.010	0.965	1.057	0.019	1.051	1,008	1.095	0.273	1.024	0.981	1.068
Gestation weeks	0.516	0.994	0.976	1.012	0.361	0.992	0.976	1.009	0.807	0.998	0.980	1.016
MSPSS	0.000	0.919	0.904	0.934	0.000	0.943	0.931	0.955	0.000	0.950	0.937	0.962
Economic	0.017	0.164	0.037	0.725	0.011	2.245	1.202	4.194	0.446	1.269	0.688	2.344
Job loss	0.006	3.401	1.412	8.194	0.000	5.906	2.821	12.362	0.000	4.788	2.507	9.147
Accessibility to healthcare professionals	0.078	0.715	0.492	1.038	0.442	1.147	0.808	1.629	0.452	0.868	0.600	1.255
Length of home-isolation	0.436	1.038	0.945	1.142	0.194	0.945	0.868	1.029	0.764	0.986	0.902	1.078
Obstetric risk	0.000	2.098	1.416	3.106	0.007	0.615	0.433	0.875	0.227	1.248	0.871	1.787
Chronic disease	0.045	0.643	0.417	0.991	0.958	1.010	0.688	1.485	0.246	1.264	0.851	1.877
Parity	0.054	1.451	0.994	2.117	0.254	1.227	0.864	1.742	0.210	0.789	0.545	1.143
Constant	0.000	421.403			0.343	1.972			0.292	2.196
Model statistics
χ2(11)	241.470				141.397				113.745
p value	<0.005				<0.005				<0.005
Nagelkerke R2	38.6%				23.7%				20.3%
Correctly classified case frequency	73.2%				68.2%				73.1%
Sensivity	80.9%				57.6%				37.3%
Spesifity	60.6%				76.8%				90%
Ppv	77.1%				66.6%				63.9%
Npv	65.8%				69.2%				75.1%

Predictor variables in model: Obstetric risk is those with at least one obstetric risk compared to those with no obstetric risk. Chronic disease is those with at least one chronic disease compared to those with no chronic disease. Job loss is those who did not lose their job and did not work compared to those who lost their jobs during the epidemic period Economy is those with moderate and good economic status compared to those with poor economic status. Accessibility to healthcare professionals is those who have remote access to healthcare professionals compared to those who do not have remote access to healthcare professionals. OR: odds ratio, ppv: positive predictive value, npv: negative predictive value

Discussion

The results of this study showed the pregnant women had high levels of moderate and severe depression, anxiety, and stress disorders during the Covid-19 outbreak. Social, economic, obstetric, and demographic factors and the general health status of women can affect the frequency of these mental disorders. In addition to these factors, pregnant women have newer challenges, demands, and needs during the epidemic period compared to those in the pre-epidemic period.

Further, pregnant women showed moderate levels anxiety and depression and low levels of stress disorder during the Covid-19 outbreak. Job loss was a common predictive risk factor for all of these mental disorders in pregnant women. The other predictive factors included the presence of an obstetric risk or a chronic physical disease, poor economic status, and advanced maternal age. In addition, an increased perception of social support had a protective effect against mental disorders.

Pregnancy is a sensitive period for mental disorders in women (Cameron et al., 2020). The frequency of prenatal depression in the pre-pandemic period has been reported to be 15–65% in different populations. Anxiety disorder has been reported in one out of every 5 pregnant women (Fawcett et al., 2019; Glover et al., 2016). To date, a limited number of studies have investigated the incidence of perinatal mental disorders among Turkish women in the pre-pandemic period, and these studies are often single-centered and regional. In one of the more extensive studies, the frequency of antenatal depression was 27.9% (Karaçam and Ançel, 2009). During the early stage of the Covid-19 pandemic, the epidemic was predicted to further increase the tendency of developing mental disorders during pregnancy because of factors such as the fear of infection, mandatory changes in prenatal visits and birth plans, and social isolation (Brooks et al., 2020; Rashidi Fakari and Simbar, 2020). To date, a limited number of studies have investigated maternal mental health during previous outbreaks (Topalidou et al., 2020). Two previous studies reported a higher frequency of antenatal anxiety during the SARS outbreak than in the pre-SARS epidemic period (Lee et al., 2006; Ng et al., 2004). In one of the earliest studies in the Covid-19 pandemic, the frequencies of maternal depression and anxiety were 34.09% and 34.55% (Cameron et al., 2020). The results of our study showed that about 7 out of 10 pregnant women had mild or more severe anxiety and depression, and 5 out of 10 women had mild or severe stress disorder. The frequencies reported in our study are much higher than those during the pre-pandemic period and during the previous SARS outbreak (Dadi et al., 2020; Fawcett et al., 2019; Karaçam and Ançel, 2009; Lee et al., 2006; Ng et al., 2004; Woody et al., 2017).

Job loss and unemployment are associated with high frequencies of depression and anxiety in the general population, regardless of the presence of epidemic conditions (Navarro-Abal et al., 2018). A study from the pre-pandemic period showed that socioeconomic deprivation increased the risk of depression, anxiety, and serious mental illness in pregnant women up to 2.5 times (Ban et al., 2012). Our results showed that job loss during the pandemic period is a common and strong risk factor for the development of anxiety, depression, and stress in pregnant women. The risks of anxiety, depression, and stress were 3, 6, and 4.8 times, respectively, higher in pregnant women who lost their jobs during the pandemic than in those who did not lose their jobs and those who did not work. The effects of job loss may be more severe, especially in countries with low- to middle-income levels and in women with critical economic balances. Furthermore, financial difficulties can have an impact on mental health, regardless of the presence of job loss. Cameron et al reported (2020) that low household income and financial difficulties were associated with perinatal anxiety and depression during the Covid-19 pandemic. The results of our study are similar to those reported by Cameron et al (2020) in that economic strain (with or without job loss) is a predictor for antenatal anxiety and depression. This relationship is particularly pronounced for depression. The risk of development of moderate to high level of depression in 2.2 times higher in women experiencing financial difficulties than in those in an economically stable condition. The anxiety and stress scores of pregnant women with poor economic status were significantly higher than those of women without financial problems.

Recent meta-analyzes during the pre-pandemic have shown an increased risk of development of anxiety and depression in women with current/past pregnancy complications defined as high-risk pregnancies (Biaggi et al., 2016; Tsakiridis et al., 2019). Results of this study showed that the presence of at least one obstetric risk was a predictive factor for development of moderate to high anxiety and depression in pregnant women during the epidemic period. The increased risk was pronounced for anxiety disorder; women with an obstetric risk have a 2-fold higher chance of developing an anxiety disorder than women without any risk. Similarly, women with any chronic disease had an increased risk of anxiety during pregnancy. However, this increase in risk was not as pronounced as in the presence of an obstetric risk. Social support is one of the unique dimensions of well-being in high-risk pregnancies, and symptoms of depression and anxiety are higher in women with high-risk pregnancies who do not get adequate support (Mirzakhani et al., 2020). Turkey imposed periodic curfews to fight the epidemic. Many indoor public places such as cafeterias, restaurants, and cinemas are closed or have limited access. Further, face-to-face communication with family, close relatives, and friends decreased because of the fear of contamination. Thus, this decrease in social support reduces the ability to cope with anxiety and increases the susceptibility to mental disorders in women with high-risk pregnancies. Studies in the pre-pandemic period have shown that perinatal social support plays a protective role in overcoming the difficulties of motherhood, and perinatal depression and anxiety are common in women with low social support (Biaggi et al., 2016; Milgrom et al., 2019). Adequate social support reduces stress more than other factors in critical events and conditions such as epidemics (Alipour et al., 2019). A common cultural aspect of the Turkish population is being in close contact with and having face-to-face communication with family and friends. Further, crowded gatherings, greeting each other with a hug, frequent visits to homes of close relatives and friends are a part of the daily cultural routine of the Turkish people. Mandatory barriers to this socialization can reduce the capacity of pregnant women to cope with mental fears, especially in countries with similar cultural habits. Our results showed that 20.9% of the pregnant women had inadequate social support. This frequency was about two times more than the frequency reported in the pregnant women in different countries during the SARS pandemic (Ng et al., 2004). In addition to differences such as duration, impact, and severity between Covid-19 and SARS outbreaks, the previously mentioned cultural characteristics may also play a role in this difference. Our results were similar to those reported in a study conducted during the SARS outbreak in that a significantly negative correlation was observed between social support scores and depression scores (Ng et al., 2004). In addition, the results of our study showed a similar negative correlation between social support scores and anxiety and stress scores. Further, our results showed that advanced maternal age increased the risk of depression in pregnant women during the epidemic period. Studies conducted in the pre-pandemic period have reported controversial findings between maternal age and mental disorders during pregnancy (Biaggi et al., 2016).

A majority of pregnant women in this study reported that they preferred the Internet and social media as their news source about the pandemic. A finding similar to that reported in our study was reported in another study conducted during a recent epidemic (Lynch et al., 2012). This finding is of great importance due to the erroneous and malicious posts that are present on the Internet and social media. In order to protect public health, specifically including women's health, it is necessary to also continue the national and international fight against false information about the epidemic, which had been called infodemic by director of the World Health Organization (Zarocostas, 2020). Current and accurate health-related information was associated with lower levels of stress, anxiety, and depression in the community during the early stage of the Covid-19 pandemic (Wang et al., 2020). In this study, approximately 50% of the women perceived news regarding the pandemic as inadequate.

Further, our results showed that the scores of anxiety, depression, and stress differ among pregnant women according to the presence of some other characteristics (sociodemographic, obstetric, etc.) and conditions (working conditions, remote access to healthcare professionals, etc.). Clues about the reasons for these differences were obtained from the open-ended questions in the study. Multiparous women had higher stress and anxiety scores than nulliparous and primiparous women. Additionally, pregnant women reported that keeping children at home during the Covid-19 epidemic, especially during curfews, was a very challenging task. This factor may explain the higher stress and anxiety scores in the multiparous women. Economic strain, another challenging factor reported by these women, reflects increased household expenditure with increased parity. Previous studies conducted during the pre-pandemic period showed no relationship between parity and mental disorders in low- and low-middle-income countries (Dadi et al., 2020; Leach et al., 2017). Higher levels of stress and anxiety observed among women in their last trimester were attributed to the upcoming birth. The statements of the women in this study show that the concerns of women regarding childbirth included the anxiety related to Covid-19 transmission during labor in addition to the known anxiety associated with birth during the pre-pandemic period. In addition, they had the fear of being alone during the labor under pandemic conditions. High scores of anxiety, depression, and stress in single or widowed women have been attributed to their economic conditions and lack of social support. High scores of anxiety and stress in women who had to leave their homes during the peak of the Covid-19 epidemic may reflect the fear of being infected with the Covid-19 virus. Similar to the results observed during the pre-pandemic period, those observed in our study showed that pregnant women who actively smoked during the Covid-19 outbreak had higher anxiety scores (Biaggi et al., 2016). Moreover, the scores of anxiety, stress, and depression were higher in women who were exposed to passive cigarette smoke at home. Factors such as loneliness, anxiety, and depression during this period can cause former users to start again or increase the number of cigarettes smoked in day. An increase in smoking or an increase in the number of cigarettes smoked in a day or exposure may increase the anxiety related to Covid-19, as a respiratory disease, or cause a feeling of guilt. An increase in mental disorders may also lead to an increase in the inclination to smoke, especially with the additional factors such as a feeling of loneliness and lack of social support (Caponnetto et al., 2020). Thus, a vicious circle may develop between smoking and mental disorders.

Conclusion

Results of our study showed high levels of anxiety, stress, and depression among pregnant women during the Covid-19 outbreak. These levels were higher than those during the pre-pandemic period. Job loss, economic difficulty, presence of an obstetric risk and/or presence of chronic disease, advanced age, and lack of social support are predictive factors for antenatal maternal mental disorders in the pandemic. Pregnant women have additional unique concerns about their pregnancies and births, which emerged during the Covid-19 outbreak.

Economic strain, frequent exposure to the news about the epidemic, and challenges of keeping children at home were reported by women as the most critical reasons underlying stress and anxiety during the epidemic period. Economic and psychosocial support and remote obstetric counseling are the most common requirements reported women during the epidemic. Many pregnant women, especially those living in big cities, reported that they wished to be able to walk safely in the open air.

Governments, health managers, midwives, obstetricians, family physicians, and the close relatives of expectant mothers play various roles in protecting maternal mental health during the Covid-19 epidemic and in similar situations if they may arise in the future. On the basis of the results of our study, we have provided our recommendations for maternal antenatal mental health. Therefore, the number of recommendations can be increased or decreased or the recommendations can be modified according to possibilities such as economic situation and infrastructure and various variables such as the local severity of the epidemic.

Recommendations for midwives and other healthcare professionals

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  Social support, obstetric counseling and support

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    Free online platforms should be provided to remotely connect pregnant women, doctors, and midwives. Up-to-date and comprehensive information about the Covid-19 epidemic and pregnancy-birth should be provided to women using this platform. Continuous communication between pregnant women should be encouraged. Meetings between pregnant women and midwives and pregnant women and doctors should be arranged to address any questions that the pregnant women may have.
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    Women should be encouraged to express their concerns/questions during their antenatal visits and births, and the healthcare professionals should ensure that they are well-informed.
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    Posters with clear up-to-date information about pregnancy during the Covid-19 epidemic should be provided in the clinic.
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    Emergency support communication lines and teams should be provided to for pregnant women. Home visits should be arranged for pregnant women when necessary, provided that personal infection protection measures are provided.
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  Psychosocial screening-support

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    Pregnant women can be screened face-to-face or online with valid and reliable scales for mental disorders. Professional psychological assistance can be provided to women with mental disorders.
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    Perceptions of social support should be investigated among pregnant women. Professional assistance can be provided to women with insufficient social support, and they can be encouraged to participate in social platforms specified in other suggestions.
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    Women who smoke can be provided with counseling and help to quit smoking. For passive smokers, information can be provided to household members.
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    Women with high-risk pregnancies should be followed up more frequently to examine mental problems and perceptions of social support.
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    Women with known chronic physical diseases should be followed-up periodically for their diseases. Information and counseling can be provided on the relationship between their physical diseases and pregnancy and childbirth. Similarly, accurate and up-to-date information should be provided regarding the relationship between their chronic disease and the Covid-19 pandemic. They should be encouraged to express their fears, concerns, and questions about their obstetric risks and chronic physical illnesses.
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  Necessary precautions should be taken to ensure the safety and “perceptions of safety” regarding the infection among pregnant women.

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    Obstetric care is should be performed away from high-risk clinics related to the Covid-19 pandemic.
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    Separate obstetric care clinics should be provided for pregnant women with definite or suspected diagnosis of infection with the Covid-19 virus.
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    Free and safe transport to maternity clinics
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    Free masks and sanitizers should be supplied in clinics
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    Social distancing and mask rules should be strictly implemented in the clinic.
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    Measures should be taken to prevent crowd in clinics (coordination of antenatal visits, preparation of separate areas for emergency and routine examinations, etc.).
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    Basic obstetric care should be provided in home settings (blood sampling, fundus-pubis measurement, blood pressure measurement, etc.).
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    All individuals entering the clinic building should be scanned through the national Covid-19 database
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    Additional measures (e.g., face shields, etc.) should be provided in the case of women who require close contact for examination (blood pressure measurement, blood sampling, childbirth etc.)
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    Antenatal visits and interventions should be completed appropriately and as soon as possible while maintaining safety

Ethical Approval

Ethical approval of the study was obtained from Istinye University Ethics Committee (04.06.2020 / 50)

Funding Sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Refika Genç Koyucu: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Supervision, Validation, Writing – review & editing. Pelin Palas Karaca: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Supervision, Validation, Writing – review & editing.

Declaration of Competing Interest

To the best of our knowledge, no conflict of interest, financial or other, exists.