Abstract
BACKGROUND
Pregnancy and COVID-19 increase the risk of mental health conditions. The stress of pregnancy, childbirth, and uncertainty about the global pandemic has negatively affected the obstetrical population.
OBJECTIVE
This study aimed to investigate the effects of the COVID-19 pandemic in terms of anxiety and depression in antenatal and postnatal mothers.
STUDY DESIGN
This was a cross-sectional observational study conducted at Dubai Hospital, United Arab Emirates, evaluating depression and anxiety (point prevalence) with the Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scale.
RESULTS
Of the 784 women approached, 438 consented to participate in our survey; 43.6% of the women screened positive for depression by the Edinburgh Postnatal Depression Scale (with a cutoff score ≥10), and 42% had a Generalized Anxiety Disorder-7 score of ≥5, indicating anxiety. Both anxiety and depression were found in 32.4% of the women; 7.5% had considered self-harm in the last 14 days, and 15% had COVID-19 during the current pregnancy. The 11.87% who had COVID-19, but before the pregnancy, had higher mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores than others. Surprisingly, the women who had COVID-19 during pregnancy had statistically significantly (P<.05) lower Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. University graduates had significantly (P<.05) higher Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. Women of Middle Eastern ethnicity (50% positive for depression and 48.5% for anxiety) were more prone to depression and anxiety compared with South Asian (29% positive for depression and 25.2% for anxiety) and African women (39.6% positive for depression and 43.4% for anxiety). There was no statistically significant difference between antenatal and postnatal patients in the prevalence of anxiety or depression.
CONCLUSION
The COVID-19 pandemic is associated with an increase in depression and anxiety in pregnant and postnatal women. Women who were more concerned about the effects of the pandemic had higher mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. Additional psychological support for women is necessary during the pandemic for maternal perinatal well-being.
Key words: COVID-19 pandemic, depression, perinatal anxiety
AJOG Global Reports at a Glance.
Why was this study conducted?
This study was conducted to assess the impact of the COVID-19 pandemic in terms of anxiety and depression in antenatal and postnatal mothers in Dubai.
Key findings
COVID-19 pandemic increased the prevalence of both anxiety and depression in obstetric patients.
What does this add to what is known?
Pregnant and postnatal women are at increased risk of anxiety and depression, but the fear of the COVID-19 infection to herself or her baby has had a significant negative impact on the mental health of the women. Our paper could contribute important new insights and improve understanding of this under-researched topic for this particular region.
Introduction
The most prevalent health disorders in women during pregnancy and the postpartum period are perinatal anxiety and depression (PAD). The perinatal period is a complicated and dynamic time for a woman's body and mind, bringing substantial physiological, emotional, and psychological changes. At least 20% to 30% of women develop at least 1 psychological condition during pregnancy and the postpartum period.1 Anxiety and depression affect 18% to 25% of pregnant women and 15% to 20% of postpartum women.2, 3, 4
The global outbreak of COVID-19, which began in Wuhan, China in December 2019, has affected the lives of billions of people around the world and claimed over 6.5 million lives to date. This has profoundly altered the daily lives of millions of individuals around the world. The pandemic's impact has been a tremendous burden and source of stress in the lives of people of all ages. Because little is known about the possible effects of COVID-19 on pregnancy and the fetus, pregnant women are at higher risk of psychological distress, which could lead to increase in the incidence of PAD.5,6
During pregnancy and the postpartum period, anxiety disorders such as panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder, and tokophobia (extreme fear of childbirth) can arise on their own or can coexist with depression. Risk factors for PAD are existing or previous psychological disorders, history of depression or anxiety during pregnancy, lack of social support from friends and relatives, stressful life events or environments, low socioeconomic status, divorce, and unstable marital relationship.7,8
PAD has a negative impact on the course of pregnancy and fetal development, and can lead to psychopathologies. A meta-analysis suggested that 1 in 3 women admitted to the hospital because of obstetrical complications have clinical signs and symptoms of anxiety or depression, which is twice the rate of the general population.9 PAD in mothers during pregnancy is associated with increased fear of childbirth, preference for cesarean delivery, preterm birth with low birthweight, low Apgar score, and adverse fetal and neurodevelopmental outcomes.10, 11, 12, 13 These women have decreased coping strategies and are at increased risk of suicide. In fact, suicide is the cause of maternal mortality in 20% of all maternal deaths in the postpartum period.14 Psychosis can reemerge or be exacerbated during pregnancy and the postnatal period.4
The United Arab Emirates (UAE) is a developed country with a multinational population of 9.98 million. Only a few studies have been conducted on postpartum depression (PPD) using the Edinburgh Postnatal Depression Scale (EPDS) in the UAE. A recent study in 2017 involving postnatal patients in peripheral health clinics yielded a crude prevalence of PPD of 33% in the UAE.15 We did not find any study on anxiety conducted using the Generalized Anxiety Disorder-7 (GAD-7) scale in the UAE with both antenatal and postnatal patients. Given the increased risk of stress- and anxiety-related pathology among perinatal women following the outbreak of COVID-19, it is now even more important to identify sociodemographic and clinical risk factors for anxiety and depression to diagnose them earlier in the antenatal and postpartum period and treat them effectively.
We aimed to determine: (1) the extent to which the COVID-19 pandemic has affected the prevalence of anxiety and depression in antenatal and postnatal women in a tertiary-care hospital; (2) the point prevalence of mental health problems in our obstetrical population; and (3) whether the effective control of the pandemic has prevented PAD in our region.
Materials and Methods
A cross-sectional observational study was conducted at Dubai Hospital, a tertiary center that receives patients from all 7 emirates of the UAE, from April 2021 to April 2022. We collected demographic information, EPDS scores, GAD-7 scale, and COVID-19–specific questionnaires from the patients who gave written informed consent.
Study participants
Participants were pregnant women attending an antenatal clinic or admitted to the hospital for obstetrical reasons and postnatal women. The age range of our participants was 16 to 52 years. Our inclusion criteria were antenatal women after 20 weeks of gestation and postnatal women who were seen in outpatient, inpatient, and emergency departments at Dubai Hospital. Women with asymptomatic COVID-19 who fit the above criteria were included. Women who had symptomatic COVID-19, those admitted for management of miscarriage in the first and second trimester or ectopic pregnancy, and those with previous known psychiatric illness were excluded from the study. Informed consent was obtained from all participants, and they were provided clarification on the aim of the study and assurance about information confidentiality. The sample size for adequate power of the study was calculated to be 350. A sample size of 350 produced a 2-sided 95% confidence interval (CI) with a width equal to 0.100 when the sample proportion is 0.350. Out of 784 participants approached, 438 were finally included in the study (Figure 1).
Figure 1.
Flowchart of participants
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
Demographic information including age, nationality, body mass index (BMI), marital status, educational level, occupation, number of people in the family, and any previous psychological illness was noted. Gestational age and any risk factors during pregnancy were noted for antenatal patients, and gestational age and mode of delivery were noted for postnatal women.
Assessment tools
Depression symptoms were assessed by EPDS, which is the most frequently used questionnaire and is internationally validated for both English and Arabic.16,17 It is a self-reporting, 10-item scale questionnaire, scoring from 0 to 3, with the minimum and maximum total scores ranging from 0 to 30 points. A cutoff point of ≥10 was used for identifying depression, ≥13 for severe depression, and a “yes” response to question 10 for suicidal ideation.
Anxiety symptoms were assessed using validated English and Arabic-translated versions of the GAD-7.18 The 7-item score assesses tension, restlessness, and irritability by scoring from 0 to 3 and by adding an overall score range from 0 to 21. A score of ≥5 was considered to indicate risk of anxiety and was used as a cutoff in our study.
Stress related to COVID-19 was assessed by specific questions, such as: “Do you worry about you or any family member being infected by COVID-19?” and “Do you worry about going for a pregnancy checkup or about the health of your baby during the pandemic?” Answers were based on a 4-point Likert scale ranging from “No, never” to “Yes, most of the time.”
Statistical analysis
Depression and anxiety scores were calculated using EPDS and GAD-7 in English and Arabic. Statistical analysis was done using IBM SPSS Statistics, version 25.0 (IBM Corp, Armonk, NY). Univariate statistics and distribution were assessed, and continuous variables were presented as mean and standard deviation or median and interquartile range. Categorical variables were expressed as frequency and percentage. The correlation between demographic factors and EPDS and GAD scores and between postnatal factors and EPDS and GAD scores of postnatal patients was calculated using chi-square tests. The Mann–Whitney U test was used for 2 independent samples and the Kruskal-Wallis test for >2 independent demographic variables. Multiple logistic regression was not needed because only 2 variables showed significant correlation. Ethical approval was obtained from the Dubai Scientific Research Ethics Committee, Dubai Health Authority (Ref: DSREC-03/2021_18).
Results
Among the screened patients, 43.6% had positive EPDS (cutoff, 10) scores. There was no statistical difference (P=.9) in depression between antenatal women (43.4% screened positive) and postnatal women (44.0% screened positive). Using the GAD-7 score, 42% of all patients screened positive for anxiety. There was no statistical difference (P=.38) in anxiety between antenatal (43.8% screened positive) and postnatal (39.6% screened positive) women. Both anxiety and depression were found in 32.4% of the women, and 7.5% of the women answered positively to question 10 of the EPDS, indicating that they had considered self-harm in the last 14 days.
In our study, the median EPDS score was 8 (minimum, 0; maximum, 24; 95% CI, 7–9), and the median GAD-7 score was 4 (minimum, 0; maximum, 21; 95% CI, 3–4). As shown in Table 1, the severity of depression is classified as mild (EPDS score, 9–12) and severe (EPDS score, ≥13), and the severity of anxiety symptoms is classified as mild (GAD-7 score, 5–9), moderate (GAD-7 score, 10–14), and severe (GAD-7 score, >15).
Table 1.
Distribution of antenatal and postnatal patients in Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 categories
| EPDS score | Negative (<10) | Mild (10–12) | Severe (≥13) | |
|---|---|---|---|---|
| Count (%) | 247 (56.4%) | 83 (18.9%) | 108 (24.7%) | |
| Antenatal | 145 (56.6%) | 49 (19.1%) | 62 (24.2%) | |
| Postnatal | 102 (56.0%) | 34 (18.7%) | 46 (25.3%) | |
| GAD-7 score | Negative (<5) | Mild (5–9) | Moderate (10–14) | Severe (>15) |
| Count (%) | 254 (58.0%) | 102 (23.3%) | 55 (12.6%) | 27 (6.2%) |
| Antenatal | 144 (56.3%) | 63 (24.6%) | 38 (14.8%) | 11 (4.3%) |
| Postnatal | 110 (60.4%) | 39 (21.4%) | 17 (9.3%) | 16 (8.8%) |
EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder-7.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
The mean age of the participants was 31.79 years (95% CI, 31.24–32.350). The youngest participant was aged 19 years and the oldest 52 years. The mean BMI was 30.95 kg/m2 (95% CI, 30.412–31.48). The lowest BMI was 16.88 kg/m2 and the highest was 56.36 kg/m2. The demographic distribution of the patients is presented in Table 2.
Table 2.
Demographic data of the study participants
| Both antenatal and postnatal patients (n=438) | Only postnatal patients (n=182) | ||
|---|---|---|---|
| Demographics | Number (%) | Demographics | Number (%) |
| Age | Gestational age at delivery | ||
| <35 y | 281 (64.5%) | Preterm | 33 (18.1%) |
| >35 y | 157 (35.5%) | Term | 149 (81.9%) |
| BMI | Type of labor | ||
| Normal | 60 (13.7%) | Spontaneous | 115 (63.2%) |
| Overweight | 136 (31.1%) | Induced | 35 (19.2%) |
| Obese | 241 (55.1%) | Not in labor | 32 (17.6%) |
| Nationality | Type of delivery | ||
| UAE | 228 (52.05%) | Normal vaginal | 101 (55.5%) |
| Non-UAE | 210 (47.95%) | Instrumental | 6 (3.3%) |
| Elective cesarean | 21 (11.5%) | ||
| Type of family | Emergency cesarean | 54 (29.7%) | |
| Nuclear | 236 (53.9%) | ||
| Joint | 202 (46.1%) | Lactation | |
| Breastfeeding satisfactorily | 168 (92.3%) | ||
| Education | Breastfeeding unsatisfactorily | 4 (2.2%) | |
| Postgraduate | 75 (17.1%) | Top feeding | 9 (4.9%) |
| University | 201 (45.9%) | Milk suppression | 1 (0.5%) |
| High school | 134 (30.6%) | ||
| None | 28 (6.4%) | Infant sex | |
| Male | 106 (58.2%) | ||
| Employment | Female | 76 (41.8%) | |
| Unemployed | 264 (60.27%) | ||
| Employed | 174 (39.72%) | Postnatal complications | |
| Yes | 31 (17.0%) | ||
| Gravidity | No | 151 (83.0%) | |
| Primi | 91 (20.8%) | ||
| Multi | 347 (79.2%) | ||
BMI, body mass index; UAE, United Arab Emirates.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023
There was no statistically significant difference in EPDS or GAD-7 scores between Arab women from the Middle East and Southeast Asian and African women (Table 3). A statistically significant difference (P<.001) was found in EPDS and GAD-7 scores between UAE nationals (EPDS >10 in 49.1% and GAD-7 >5 in 47.8%) and expatriates (EPDS >10 in only 37.6% and GAD-7 >5 in only 35.7%). Women with office jobs were as depressed and anxious as housewives (no statistically significant difference in EPDS or GAD-7 scores). Table 3 further elaborates on the correlation between EPDS and GAD-7 scores and demographic factors.
Table 3.
Correlation of demographic factors of the delivered (postnatal) participants with Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores
| Demographics | EPDS (<10) | EPDS (≥10) | P value | GAD-7 (<5) | GAD-7 (≥5) | P value |
|---|---|---|---|---|---|---|
| Age group | ||||||
| <35 y | 158 (56.2%) | 123 (43.8%) | .9 | 160 (56.9%) | 121 (43.1%) | .55 |
| >35 y | 89 (56.7%) | 68 (43.3%) | 94 (59.9%) | 63 (40.1%) | ||
| BMI categories | ||||||
| Normal <24.99 | 35 (58.3%) | 25 (41.7%) | .9 | 32 (53.3%) | 28 (46.7%) | .69 |
| Overweight | 75 (55.1%) | 61 (44.9%) | 78 (57.4%) | 58 (42.6%) | ||
| Obese >30.00 | 137 (56.8%) | 104 (43.2%) | 143 (59.3%) | 98 (40.7%) | ||
| Region | ||||||
| Middle East | 139 (50.0%) | 139 (50.0%) | .00 | 144 (51.8%) | 134 (48.2%) | .00 |
| Southeast Asia | 76 (71.0%) | 31 (29.0%) | 80 (74.8%) | 27 (25.2%) | ||
| Africa | 32 (60.4%) | 21 (39.6%) | 30 (56.6%) | 23 (43.4%) | ||
| Type of family | ||||||
| Nuclear | 137 (58.1%) | 99 (41.9%) | .44 | 142 (60.2%) | 94 (39.8%) | .31 |
| Joint | 110 (54.5%) | 92 (45.5%) | 112 (55.4%) | 90 (44.6%) | ||
| Education | ||||||
| Postgraduate | 37 (49.3%) | 38 (50.7%) | .08 | 42 (56.0%) | 33 (44.0%) | .44 |
| University | 121 (60.2%) | 80 (39.8%) | 118 (58.7%) | 83 (41.3%) | ||
| High school | 69 (51.5%) | 65 (48.5%) | 74 (55.2%) | 60 (44.8%) | ||
| None | 20 (71.4%) | 8 (28.6%) | 20 (71.4%) | 8 (28.6%) | ||
| Married life | ||||||
| <3 y | 67 (54.5%) | 56 (45.5%) | .61 | 67 (54.5%) | 56 (45.5%) | .35 |
| >3 y | 180 (57.1%) | 135 (42.9%) | 187 (59.4%) | 128 (40.6%) | ||
| Employment | ||||||
| Unemployed | 148 (56.1%) | 116 (43.9%) | .86 | 152 (57.6%) | 112 (42.4%) | .82 |
| Employed | 99 (56.9%) | 75 (43.1%) | 102 (58.6%) | 72 (41.4%) | ||
| Gravidity | ||||||
| Primipara | 51 (56.0%) | 40 (44.0%) | .94 | 52 (57.1%) | 39 (42.9%) | .85 |
| Multipara | 196 (56.5%) | 151 (43.5%) | 202 (58.2%) | 145 (41.8%) | ||
BMI, body mass index; EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder-7.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
Significantly more women with preterm delivery screened positive for anxiety by GAD-7 score compared with women with term delivery. Similarly, women with breastfeeding problems had significantly more GAD-7 scores ≥5 compared with women without such problems. Thus, women with preterm delivery and difficulty in breastfeeding had high anxiety levels, but for all other postnatal factors, no statistically significant differences in depression and anxiety were observed (Table 4).
Table 4.
Correlation of obstetrical outcomes of the delivered (postnatal) participants with Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores
| Characteristics | EPDS (<10) | EPDS (≥10) | P value | GAD-7 (<5) | GAD-7 (≥5) | P value |
|---|---|---|---|---|---|---|
| Gestational age at delivery | ||||||
| Preterm | 18 (54.%) | 15 (45.5%) | .8 | 15 (45.5%) | 18 (54.5%) | .05 |
| Term | 84 (56.4%) | 65 (43.6%) | 95 (63.8%) | 54 (36.2%) | ||
| Type of labor | ||||||
| Spontaneous | 64 (55.7%) | 51 (44.3%) | .56 | 71 (61.7%) | 44 (38.3%) | .64 |
| Induced | 22 (62.9%) | 13 (37.1%) | 22 (62.9%) | 13 (37.1%) | ||
| Not in labor | 16 (50.0%) | 16 (50.0%) | 17 (53.15) | 15 (46.9%) | ||
| Type of delivery | ||||||
| Normal vaginal | 57 (56.4%) | 44 (43.6%) | .57 | 60 (59.4%) | 41 (40.6%) | .55 |
| Instrumental | 4 (66.7%) | 2 (33.3%) | 5 (83.3%) | 1 (16.7%) | ||
| Elective cesarean delivery | 9 (42.9%) | 12 (57.1%) | 11 (52.4%) | 10 (47.6%) | ||
| Emergency cesarean delivery | 32 (59.3%) | 22 (40.7%) | 34 (63.0%) | 20 (37.0%) | ||
| Lactation | ||||||
| Breastfeeding satisfactorily | 97 (57.7%) | 71 (42.3%) | .31 | 106 (63.1%) | 62 (36.9%) | .03 |
| Breastfeeding unsatisfactorily | 1 (25%) | 3 (75%) | 1 (25%) | 3 (75%) | ||
| Top feeding | 4 (44.4%) | 5 (55.6%) | 2 (22.2%) | 7 (77.8%) | ||
| Milk suppression | 0 | 1 (100%) | 1 (100%) | 0 | ||
| Infant sex | ||||||
| Male | 56 (52.8%) | 50 (47.2%) | .30 | 69 (65.1%) | 37 (34.9%) | .12 |
| Female | 46 (60.5%) | 30 (39.5%) | 41 (53.9%) | 35 (46.1%) | ||
| Postnatal complications | ||||||
| Yes | 15 (48.4%) | 16 (51.6%) | .34 | 16 (51.6%) | 15 (48.4%) | .27 |
| No | 87 (57.6%) | 64 (42.4%) | 94 (62.3%) | 57 (37.7%) | ||
EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder-7.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
Of the 438 participants, 118 (27%) had COVID-19 before the survey, and 66 (15%) had COVID-19 during pregnancy. The 11.87% who had COVID-19 before the pregnancy had higher EPDS and GAD-7 score than others. Surprisingly, the women who had COVID-19 during pregnancy had statistically significant (P=.0005) lower EPDS and GAD-7 scores. Women who were worried about COVID-19 infection in themselves and their children were found to be significantly more depressed and anxious compared with women who were not worried. Becuse the data were skewed, independent Kruskal-Wallis tests were used to correlate the COVID-19–specific questions with the EPDS and GAD-7 score, as shown in Figure 2.
Figure 2.
Statistical analysis of the COVID-19 specific questionnaire
EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder-7.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
Discussion
The COVID-19 pandemic has had an impact on the mental health of pregnant and postnatal women, particularly in the Middle East. There is a significant gap in research on mental health in pregnant and postnatal women in the Middle East region, where mental health issues are considered taboo topics and rarely discussed even by healthcare providers.
Depression and anxiety before COVID-19
Depression and anxiety are common medical conditions in women during the perinatal period and are associated with serious consequences. Untreated perinatal depression may negatively affect birth and breastfeeding outcomes and increase the risk for behavioral and impaired social, cognitive, and emotional development of the infant. In severe cases, women may consider harming themselves or the newborn infant. Although it is imperative to recognize perinatal depression, it is often overlooked, especially because patients may be reluctant to reveal their symptoms. Therefore, many women with perinatal depression are not diagnosed, and even when they are, only some receive follow-up treatment.19
Until 2017, the worldwide incidence of PPD varied from approximately 9.5% in high-income countries, approximately 20.8% in middle-income countries, and 25.8% in low-income countries.20,21 There is a wide variation of prevalence, from 0.5% in some countries to 60% in others; on average, PPD was found in 17.22% of women (95% CI, 16.00–18.5).22 Table 5 shows a comparison of the prevalence of anxiety and depression between various studies conducted before and after the outbreak of COVID-19.
Table 5.
Comparison of prevalence of anxiety and depression in different studies
| Country | Study | Year | EPDS | Antenatal depression | Postnatal depression | Antenatal anxiety | Postnatal anxiety | Both anxiety and depression | Sample size |
|---|---|---|---|---|---|---|---|---|---|
| Before COVID-19 | |||||||||
| Canada | Lanes et al,23 | 2011 | ≥10 | 8.69% | 6421 | ||||
| China | Nisar et al,24 | 2020 | unclear | 19.70% | 14.80% | unclear | |||
| Egypt | Saleh et al,25 | 2013 | ≥13 | 17.90% | 120 | ||||
| India | Kale et al,26 | 2019 | ≥13 | 4.00% | 123 | ||||
| Oman | Al-Azri et al,27 | 2016 | ≥13 | 24.30% | 959 | ||||
| Oman | Al Hinai FI and Al Hinai SS,28 | 2014 | ≥13 | 12.00% | 282 | ||||
| Saudi Arabia | Alqahtani et al,29 | 2018 | ≥14 | 26.80% | 23.60% | 575 | |||
| United Arab Emirates | Alhammadi et al,15 | 2017 | ≥10 | 33.00% | 504 | ||||
| After COVID-19 | |||||||||
| Canada | Lebel et al,30 | 2020 | ≥13 | 37.00% | 57.00% | 1987 | |||
| Canada | Cameron et al,31 | 2020 | ≥13 | 33.00% | 36.27% | 641 | |||
| China, Wuhan | Sun et al,32 | 2020 | ≥9 | 33.71% | 2883 | ||||
| China | Wu et al,33 | 2020 | ≥10 | 29.60% | 1285 | ||||
| China | An et al,34 | 2021 | ≥10 | 56.90% | 209 | ||||
| China | Jiang et al,35 | 2021 | ≥10 | 45.90% | 18.10% | 1873 | |||
| China | Liang et al,36 | 2020 | ≥10 | 30.00% | 845 | ||||
| Egypt | Khamees et al,37 | 2021 | ≥14 | 44.00% | 120 | ||||
| Greece | Tsakiridis et al,38 | 2021 | ≥13 | 13.50% | 34.10% | 505 | |||
| Israel | Pariente et al,39 | 2020 | ≥10 | 16.70% | 223 | ||||
| Israel | Sade et al,40 | 2020 | ≥10 | 25.00% | 279 | ||||
| Italy | Spinola et al,41 | 2020 | ≥12 | 44.40% | 243 | ||||
| Italy | Ostacoli et al,42 | 2020 | ≥11 | 44.20% | 163 | ||||
| Kuwait | Khamees et al,37 | 2021 | ≥14 | 44.20% | 45.00% | 120 | |||
| Mexico | Suárez-Rico et al,43 | 2021 | ≥13 | 39.50% | 46.10% | 293 | |||
| Spain | Lubián López et al,44 | 2021 | ≥10 | 35.00% | 44.20% | 514 | |||
| Spain | Motrico et al,45 | 2022 | ≥10 | 44.80% | 49.00% | 32.70% | 33.70% | 29.20% | 3356 |
| Turkey | Durankuş et al,46 | 2020 | ≥13 | 35.40% | 260 | ||||
| Turkey | Guvenc et al,47 | 2021 | ≥13 | 34.00% | 212 | ||||
| United Kingdom | Fallon et al,48 | 2021 | ≥13 | 43.00% | 614 | ||||
| United States | Perzow et al,49 | 2021 | ≥10 | 35.00% | 135 | ||||
| United Arab Emirates | Our study | 2022 | ≥10 | 43.40% | 44.00% | 43.80% | 39.60% | 32.40% | 438 |
EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder-7; SR, systematic review.
Tambawala. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023.
Prevalence of depression and anxiety in the Middle East compared with the rest of the world
Only 8 of the 512 participants in our study had a known history of psychiatric illness, which may indicate that women in the Middle East are hesitant to seek treatment for mental health issues because of the stigma attached. A study in 2016 in the Middle East showed a prevalence rate of postnatal depression of 33%, out of which 16% of women had severe depression and 17% had moderate depression. The prevalence of suicidal ideation was 3%. In our study, the point prevalence of perinatal depression was 43.6%, which is much higher than the prevalence found in a study conducted before the pandemic in the region by Alhammadi et al15 (33%). Our prevalence is high compared with Western populations but almost similar to Arab-world statistics. Cultural variations, diverse reporting practices, different viewpoints on mental health issues and stigma, socioeconomic class, poverty, poor social services, deficient nutrition, elevated stress, and biological factors can all be related to this broader continuum.
Robust prevalence studies are sparse in most South Asian countries; available data suggest that 1 in 4 pregnant women are likely to experience antenatal depression in the region. Prevalence rates for India (17.74%; 95% CI, 11.19–26.96) and Sri Lanka (12.95%; 95% CI, 8.29–19.68) were lower compared with the overall prevalence, whereas prevalence rates for Pakistan (32.2%; 95% CI, 23.11–42.87) and Nepal (50%; 95% CI, 35.64–64.36) were higher. This was similar to the prevalence rate of depression and anxiety in South Asian women found in our study.50
Depression and anxiety owing to COVID-19
Previous studies on similar epidemics such as SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) have reported that social isolation and health service disruptions could detrimentally affect mental health and psychological well-being.51 Similar to previous viral epidemics, the COVID-19 pandemic was also found to be associated with psychological distress and increased mental health symptoms such as depression and anxiety because of social isolation and health service disruptions. A meta-analysis by Chen et al21 showed an overall prevalence of PPD of 34% (95% CI, 21–46) during the COVID-19 pandemic. Previous research likewise found that during disasters or unexpected events, the prevalence rates of mental disorders are significantly higher than those among the general population.21 Therefore, the effects of COVID-19 on the prevalence of PPD and its risk factors need to be explored, and applying tailored interventions based on research data is an urgent necessity.52
A cross-sectional study conducted in Wuhan from December 2019 to March 2020 showed a perinatal depression prevalence of 33.71%, which increased as the COVID-19 pandemic worsened. The dynamic change in perinatal depression prevalence was associated with the progression of the COVID-19 pandemic among new mothers who were exposed to the pandemic. An elevated risk of postnatal depression was also observed during the COVID-19 pandemic.32 As in our study, although the overall risk of perinatal depression increased during the COVID-19 pandemic, many contributory factors require further evaluation.
Similar to our study, Lebel et al30 found that for pregnant individuals, rates of anxiety and depression increased during the COVID-19 pandemic. They demonstrated that symptoms of anxiety and depression were modulated by various concerns, including the potential threat to one's own life, harm to the infant, and not receiving needed care. Although mothers reported these concerns, it is possible that a healthy delivery, which characterizes most deliveries even during the pandemic, was enough to assuage these underlying concerns and quell any lasting symptoms of anxiety and depression that may have contributed to the development of PPD.
Anxiety during COVID-19
Anxiety is the concomitant factor associated with depression. Antenatal anxiety is associated with increased childbirth fear leading to increased cesarean delivery rate, and decreased coping mechanisms leading to neonatal implications such as preterm birth and poor child development.53, 54, 55 Postnatal anxiety is associated with negative and overcontrolling maternal behaviors that increase the likelihood of internalizing and externalizing difficulties in the child.56
During COVID-19, pregnant women had anxiety and fear of potential harm to unborn children either because of vertical transmission or contact after birth.57,58 Before the pandemic, according to Dennis et al,2 the prevalence of anxiety was 22.9% antenatally and 17.8% postnatally. Only a few studies have analyzed the prevalence of anxiety during the pandemic. The prevalence found in our study (42%) was almost double the prepandemic prevalence, but was similar to those found in an Ethiopian and a Polish study.59,60
Antenatal depression during COVID-19
The prevalence of depression and anxiety is higher postnatally because of the increased responsibilities of caring for the infant and because of hormonal changes, as mentioned in various studies. During the COVID-19 pandemic, the prevalence of antenatal depression and anxiety has increased and become similar to postpartum percentages. Adrianto et al61 found an overall depression prevalence of 31.49% in antenatal women, as opposed to 27.6% in postpartum women. The observed antenatal depression prevalence was attributed to fear of contracting COVID-19 and its complications during pregnancy. Our study also found similar percentages for antenatal and postnatal women, both for depression and anxiety. A study conducted in Kuwait showed a high prevalence of anxiety (45%) and depression (44%), as indicated by EPDS scores of >14. Nearly 77.5% of women thought that the COVID-19 pandemic will affect their pregnancy.37
Limitations
This study was only a cross-sectional prevalence study and did not include analysis of follow-up data. Long-term follow-up of the women who screened positive is needed to know the full impact of COVID-19 on mental health. In addition, the unique cultural and social factors that may influence the mental health of pregnant and postdelivery women must be considered because they may compound the challenges, and could be a vital area of further research.
Conclusions
There is a need for early screening for depression and anxiety in the obstetrical population, especially when taking into account COVID-19–related distress. Early identification by screening is necessary to prevent the later sequelae of depression, and can significantly improve patient care. Findings highlight the need for recognition of mental health issues in the Middle Eastern region, and that depression and anxiety in pregnant and postnatal women should be prioritized in health policy, clinical practice, and resource allocation at regional and national levels for prevention, diagnosis, and treatment. Collection of complete medical history and routine use of screening tools such as EPDS and GAD-7 to detect at-risk women would allow the early detection and prevention of perinatal depression and anxiety. EPDS and GAD-7 scores should be routinely used to screen pregnant and postnatal women, and those screening positive should be immediately provided with guidance, support, and treatment.
Acknowledgments
We would like to thank Marwan Abdelrahim Zidan, Ph.D for helping in statistical analysis and Esraa Osman Ismail MBBS, Filsan Bashir Muse, MBBS, Amina Abdulrazzak Hassan, MBBS, Hind Abdulla Essa, MBBS, Alia Karim, MBBS, Mae Belen, RN, and nursing staff of Obstetrics and Gynecology department of Dubai Hospital for immense help in data collection.
Footnotes
The authors report no conflict of interest.
The study was supported by Dubai Academic Health Corporation.
Ethical approval was obtained from the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority (Ref: DSREC-03/2021_18). Informed consent was obtained from all participants, who were provided clarification on the aim of the study and assurance about information confidentiality.
The datasets used and/or analyzed for this study are available from the corresponding author on reasonable request.
Cite this article as: Tambawala ZY, Saquib S, Salman A, et al. Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates. Am J Obstet Gynecol Glob Rep 2023;XX:x.ex–x.ex.
References
- 1.Uguz F, Yakut E, Aydogan S, Bayman MG, Gezginc K. Prevalence of mood and anxiety disorders during pregnancy: a case-control study with a large sample size. Psychiatry Res. 2019;272:316–318. doi: 10.1016/j.psychres.2018.12.129. [DOI] [PubMed] [Google Scholar]
- 2.Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry. 2017;210:315–323. doi: 10.1192/bjp.bp.116.187179. [DOI] [PubMed] [Google Scholar]
- 3.Woody CA, Ferrari AJ, Siskind DJ, Whiteford HA, Harris MG. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017;219:86–92. doi: 10.1016/j.jad.2017.05.003. [DOI] [PubMed] [Google Scholar]
- 4.National Institute for Health and Care Excellence . 2020. Antenatal and postnatal mental health: clinical management and service guidance.www.nice.org.uk/guidance/cg192 Available at: Accessed 11 February 2022. [PubMed] [Google Scholar]
- 5.Chen H, Selix N, Nosek M. Perinatal anxiety and depression during COVID-19. J Nurse Pract. 2021;17:26–31. doi: 10.1016/j.nurpra.2020.09.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395:e37–e38. doi: 10.1016/S0140-6736(20)30309-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Fairbrother N, Young AH, Janssen P, Antony MM, Tucker E. Depression and anxiety during the perinatal period. BMC Psychiatry. 2015;15:206. doi: 10.1186/s12888-015-0526-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Abdollahi F, Zarghami M, Sazlina SG, Zain AM, Mohammad AJ, Lye MS. Prediction of incidence and bio-psycho-socio-cultural risk factors of post-partum depression immediately after birth in an Iranian population. Arch Med Sci. 2016;12:1043–1051. doi: 10.5114/aoms.2016.58642. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Toscano M, Royzer R, Castillo D, Li D, Poleshuck E. Prevalence of depression or anxiety during antepartum hospitalizations for obstetric complications: a systematic review and meta-analysis. Obstet Gynecol. 2021;137:881–891. doi: 10.1097/AOG.0000000000004335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Risk factors for and perinatal outcomes of major depression during pregnancy: a population-based analysis during 2002-2010 in Finland. BMJ Open. 2014;4 doi: 10.1136/bmjopen-2014-004883. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Eastwood J, Ogbo FA, Hendry A, Noble J, Page A. Early Years Research Group (EYRG). The impact of antenatal depression on perinatal outcomes in Australian women. PLoS One. 2017;12 doi: 10.1371/journal.pone.0169907. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry. 2012;25:141–148. doi: 10.1097/YCO.0b013e3283503680. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Stein A, Pearson RM, Goodman SH, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384:1800–1819. doi: 10.1016/S0140-6736(14)61277-0. [DOI] [PubMed] [Google Scholar]
- 14.Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005;8:77–87. doi: 10.1007/s00737-005-0080-1. [DOI] [PubMed] [Google Scholar]
- 15.Alhammadi SM, Hashem LA, Abusbeih ZR, et al. Predictors of postpartum depression in Dubai, a rapidly growing multicultural society in The United Arab Emirates. Psychiatr Danub. 2017;29:313–322. [PubMed] [Google Scholar]
- 16.Cox J. Use and misuse of the Edinburgh Postnatal Depression Scale (EPDS): a ten point ‘survival analysis’. Arch Womens Ment Health. 2017;20(6):789–790. doi: 10.1007/s00737-017-0789-7. [DOI] [PubMed] [Google Scholar]
- 17.Ghubash R, Abou-Saleh MT, Daradkeh TK. The validity of the Arabic Edinburgh Postnatal Depression Scale. Soc Psychiatry Psychiatr Epidemiol. 1997;32:474–476. doi: 10.1007/BF00789142. [DOI] [PubMed] [Google Scholar]
- 18.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092–1097. doi: 10.1001/archinte.166.10.1092. [DOI] [PubMed] [Google Scholar]
- 19.Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106:1071–1083. doi: 10.1097/01.AOG.0000183597.31630.db. [DOI] [PubMed] [Google Scholar]
- 20.Dadi AF, Miller ER, Mwanri L. Postnatal depression and its association with adverse infant health outcomes in low- and middle-income countries: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2020;20:416. doi: 10.1186/s12884-020-03092-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Chen J, Cross WM, Plummer V, Lam L, Tang S. A systematic review of prevalence and risk factors of postpartum depression in Chinese immigrant women. Women Birth. 2019;32:487–492. doi: 10.1016/j.wombi.2018.11.019. [DOI] [PubMed] [Google Scholar]
- 22.Wang Z, Liu J, Shuai H, et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatry. 2021;11:543. doi: 10.1038/s41398-021-01663-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Lanes A, Kuk JL, Tamim H. Prevalence and characteristics of postpartum Depression symptomatology among Canadian women: a cross-sectional study. BMC Public Health. 2011;11:302. doi: 10.1186/1471-2458-11-302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nisar A, Yin J, Waqas A, et al. Prevalence of perinatal depression and its determinants in Mainland China: a systematic review and meta-analysis. J Affect Disord. 2020;277:1022–1037. doi: 10.1016/j.jad.2020.07.046. [DOI] [PubMed] [Google Scholar]
- 25.Saleh el-S, El-Bahei W, del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat. 2013;9:15–24. doi: 10.2147/NDT.S37156. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Kale DP, Tambawala ZY, Rajput NM. Postpartum depression prevalence in a Tertiary Care Hospital in Mumbai, Maharashtra, India. J South Asian Feder Obst Gynae. 2019;11:239–242. [Google Scholar]
- 27.Al-Azri M, Al-Lawati I, Al-Kamyani R, et al. Prevalence and risk factors of antenatal depression among Omani women in a primary care setting: cross-sectional study. Sultan Qaboos Univ Med J. 2016;16:e35–e41. doi: 10.18295/squmj.2016.16.01.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Al Hinai FI, Al Hinai SS. Prospective study on prevalence and risk factors of postpartum depression in al-Dakhliya governorate in Oman. Oman Med J. 2014;29:198–202. doi: 10.5001/omj.2014.49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Alqahtani AH, Al Khedair K, Al-Jeheiman R, Al-Turki HA, Al Qahtani NH. Anxiety and depression during pregnancy in women attending clinics in a University Hospital in Eastern Province Of Saudi Arabia: prevalence and associated factors. Int J Womens Health. 2018;10:101–108. doi: 10.2147/IJWH.S153273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Lebel C, MacKinnon A, Bagshawe M, Tomfohr-Madsen L, Giesbrecht G. Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. J Affect Disord. 2020;277:5–13. doi: 10.1016/j.jad.2020.07.126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Cameron EE, Joyce KM, Delaquis CP, Reynolds K, Protudjer JLP, Roos LE. Maternal psychological distress & mental health service use during the COVID-19 pandemic. J Affect Disord. 2020;276:765–774. doi: 10.1016/j.jad.2020.07.081. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Sun G, Wang Q, Lin Y, et al. Perinatal depression of exposed maternal women in the COVID-19 pandemic in Wuhan. China. Front Psychiatry. 2020;11 doi: 10.3389/fpsyt.2020.551812. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.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 doi: 10.1016/j.ajog.2020.05.009. 240.e1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.An R, Chen X, Wu Y, et al. A survey of postpartum depression and health care needs among Chinese postpartum women during the pandemic of COVID-19. Arch Psychiatr Nurs. 2021;35:172–177. doi: 10.1016/j.apnu.2021.02.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Jiang H, Jin L, Qian X, et al. Maternal mental health status and approaches for accessing antenatal care information during the COVID-19 epidemic in China: cross-sectional study. J Med Internet Res. 2021;23:e18722. doi: 10.2196/18722. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Liang P, Wang Y, Shi S, Liu Y, Xiong R. Prevalence and factors associated with postpartum depression during the COVID-19 pandemic among women in Guangzhou, China: a cross-sectional study. BMC Psychiatry. 2020;20:557. doi: 10.1186/s12888-020-02969-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Khamees RE, Taha OT, Ali TYM. Anxiety and depression during pregnancy in the era of COVID-19. J Perinat Med. 2021;49:674–677. doi: 10.1515/jpm-2021-0181. [DOI] [PubMed] [Google Scholar]
- 38.Tsakiridis I, Dagklis T, Mamopoulos A, Athanasiadis A, Pearson R, Papazisis G. Antenatal depression and anxiety during the COVID-19 pandemic: a cross-sectional study in pregnant women from routine health care contact in Greece. J Perinat Med. 2021;49:656–663. doi: 10.1515/jpm-2020-0473. [DOI] [PubMed] [Google Scholar]
- 39.Pariente G, Wissotzky Broder O, Sheiner E, et al. Risk for probable post-partum depression among women during the COVID-19 pandemic. Arch Womens Ment Health. 2020;23:767–773. doi: 10.1007/s00737-020-01075-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Sade S, Sheiner E, Wainstock T, et al. Risk for depressive symptoms among hospitalized women in high-risk pregnancy units during the COVID-19 pandemic. J Clin Med. 2020;9:2449. doi: 10.3390/jcm9082449. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Spinola O, Liotti M, Speranza AM, Tambelli R. Effects of COVID-19 epidemic lockdown on postpartum depressive symptoms in a sample of Italian mothers. Front Psychiatry. 2020;11 doi: 10.3389/fpsyt.2020.589916. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Ostacoli L, Cosma S, Bevilacqua F, et al. Psychosocial factors associated with postpartum psychological distress during the Covid-19 pandemic: a cross-sectional study. BMC Pregnancy Childbirth. 2020;20:703. doi: 10.1186/s12884-020-03399-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Suárez-Rico BV, Estrada-Gutierrez G, Sánchez-Martínez M, et al. Prevalence of depression, anxiety, and perceived stress in postpartum Mexican women during the COVID-19 lockdown. Int J Environ Res Public Health. 2021;18:4627. doi: 10.3390/ijerph18094627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Lubián López DM, Butrón Hinojo CA, Arjona Bernal JE, et al. Resilience and psychological distress in pregnant women during quarantine due to the COVID-19 outbreak in Spain: a multicentre cross-sectional online survey. J Psychosom Obstet Gynaecol. 2021;42:115–122. doi: 10.1080/0167482X.2021.1896491. [DOI] [PubMed] [Google Scholar]
- 45.Motrico E, Domínguez-Salas S, Rodríguez-Domínguez C, Gómez-Gómez I, Rodríguez-Muñoz MF, Gómez-Baya D. The impact of the COVID-19 pandemic on perinatal depression and anxiety: a large cross-sectional study in Spain. Psicothema. 2022;34:200–208. doi: 10.7334/psicothema2021.380. [DOI] [PubMed] [Google Scholar]
- 46.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. 2022;35:205–211. doi: 10.1080/14767058.2020.1763946. [DOI] [PubMed] [Google Scholar]
- 47.Guvenc G, Yesilcinar İ, Ozkececi F, et al. Anxiety, depression, and knowledge level in postpartum women during the COVID-19 pandemic. Perspect Psychiatr Care. 2021;57:1449–1458. doi: 10.1111/ppc.12711. [DOI] [PubMed] [Google Scholar]
- 48.Fallon V, Davies SM, Silverio SA, Jackson L, De Pascalis L, Harrold JA. Psychosocial experiences of postnatal women during the COVID-19 pandemic. A UK-wide study of prevalence rates and risk factors for clinically relevant depression and anxiety. J Psychiatr Res. 2021;136:157–166. doi: 10.1016/j.jpsychires.2021.01.048. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Perzow SED, Hennessey EP, Hoffman MC, Grote NK, Davis EP, Hankin BL. Mental health of pregnant and postpartum women in response to the COVID-19 pandemic. J Affect Disord Rep. 2021;4 doi: 10.1016/j.jadr.2021.100123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Mahendran R, Puthussery S, Amalan M. Prevalence of antenatal depression in South Asia: a systematic review and meta-analysis. J Epidemiol Community Health. 2019;73:768–777. doi: 10.1136/jech-2018-211819. [DOI] [PubMed] [Google Scholar]
- 51.Du L, Chen YM, Li Y, Yuan W, Wang JS. Prevalence of depression during the SARS, MERS, and COVID-19 pandemics: a protocol for overview of systematic reviews. Medicine. 2020;99:e22235. doi: 10.1097/MD.0000000000022235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Dadi AF, Miller ER, Bisetegn TA, Mwanri L. Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review. BMC Public Health. 2020;20:173. doi: 10.1186/s12889-020-8293-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.George A, Luz RF, De Tychey C, Thilly N, Spitz E. Anxiety symptoms and coping strategies in the perinatal period. BMC Pregnancy Childbirth. 2013;13:233. doi: 10.1186/1471-2393-13-233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Rubertsson C, Hellström J, Cross M, Sydsjö G. Anxiety in early pregnancy: prevalence and contributing factors. Arch Womens Ment Health. 2014;17:221–228. doi: 10.1007/s00737-013-0409-0. [DOI] [PubMed] [Google Scholar]
- 55.Ibanez G, Charles MA, Forhan A, et al. Depression and anxiety in women during pregnancy and neonatal outcome: data from the EDEN mother-child cohort. Early Hum Dev. 2012;88:643–649. doi: 10.1016/j.earlhumdev.2012.01.014. [DOI] [PubMed] [Google Scholar]
- 56.McLeod BD, Wood JJ, Weisz JR. Examining the association between parenting and childhood anxiety: a meta-analysis. Clin Psychol Rev. 2007;27:155–172. doi: 10.1016/j.cpr.2006.09.002. [DOI] [PubMed] [Google Scholar]
- 57.Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol. 2020;37:861–865. doi: 10.1055/s-0040-1710050. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, et al. Vertical transmission of coronavirus disease 19 (COVID-19) from infected pregnant mothers to neonates: a review. Fetal Pediatr Pathol. 2020;39:246–250. doi: 10.1080/15513815.2020.1747120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Abegaz MY, Muche HA, Aynalem GL. Determinants of pregnancy-related anxiety among women attending antenatal checkup at public health institutions in Debre Markos Town, Ethiopia. Depress Res Treat. 2022;2022 doi: 10.1155/2022/6935609. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Ilska M, Brandt-Salmeri A, Kołodziej-Zaleska A, Preis H, Rehbein E, Lobel M. Anxiety among pregnant women during the first wave of the COVID-19 pandemic in Poland. Sci Rep. 2022;12:8445. doi: 10.1038/s41598-022-12275-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Adrianto N, Caesarlia J, Pajala FB. Depression in pregnant and postpartum women during COVID-19 pandemic: systematic review and meta-analysis. Obstet Gynecol Sci. 2022;65:287–302. doi: 10.5468/ogs.21265. [DOI] [PMC free article] [PubMed] [Google Scholar]