Effects of coronavirus 19 pandemic on maternal anxiety during pregnancy: a prospectic observational study

Introduction

The coronavirus 2019-nCoV (COVID-19) infection is a public health emergency of international concern in which a coronavirus has been identified as the cause of an outbreak of respiratory illness. It was first detected in Wuhan, China [1], spreading rapidly to other countries worldwide [2], [3]. On the 12th March 2020, the World and Health Organization (WHO) announced the new Coronavirus outbreak pandemic and according to WHO official website of the World Health Organization [4] more than 2,500,000 people have been confirmed to have a COVID-19 infection globally.

Pandemics pose a challenge to psychological resilience and can lead to heightened levels of stress [5]. Anxiety is a common response to any stressful situation. Pregnant women, as well as mental and physical changes during gestation, are more likely to be at risk. Prevalence of anxiety disorder during pregnancy, in developed and developing countries, are 10 and 25%, respectively [6], [7]. Anxiety symptoms during pregnancy have emerged as an independent risk factor for adverse obstetric and developmental outcomes [8]. Antenatal anxiety may be a risk factor for maternal mental health problems, such as an increased likelihood of postnatal depression [9] and impaired bonding [10], and obstetric complications, such as length of labor [11], premature delivery [12] and impaired fetal growth [13]. We therefore hypothesized that COVID-19 pandemic may have a profound impact on the level of anxiety of pregnant women that may be different according to their basal level of anxiety and pregnancy characteristics.

The aim of the study is to evaluate the psychological impact of COVID-19 pandemic on pregnant women in the period of maximum spread of the virus and its relationship with pregnancies characteristics.

Materials and methods

An anonymous online semi-structured questionnaire was developed using Google forms (https://docs.google.com/forms Google Mountain View, CA, USA). The link of the questionnaire was sent through emails, to the women that have attended from January 2020 to February 2020 the antenatal clinic of Università di Roma Tor Vergata Ospedale Cristo Re Rome Italy for ultrasonographic examination. All the women underwent a detailed ultrasound scan including assessment of fetal growth and rule out of fetal anomalies scan. The indications for the ultrasound scan were routine antenatal care (i. e., 11 + 0 − 13 + 6 weeks ultrasound scan, second trimester anatomic scan and third trimester growth assessment). Criteria of inclusions were singleton pregnancies and reassuring results from ultrasonographic examination. Criteria of exclusion were the presence of any fetal or maternal complications.

The questionnaire is structured in two sections: section A finalized to acquire in 18 items maternal characteristics and to test women’s knowledge and concerns about perinatal complications; section B containing 40 items validate scale for scoring anxiety: state–trait anxiety inventory (STAI) [14] (Supplemental Material 1).

Sociodemographic data were also collected including maternal age, gestational age at the receipt of the questionnaire, pregnancy characteristics, level of education, marital and employment status.

To evaluate the maternal concern about perinatal complication induced by COVID-19 the following fears were considered: fetal structural anomalies, growth anomalies and preterm birth.

The STAI is a 40-items scale, using a 4-point Likert scale for each item. The scale can be used to measure both trait anxiety (how dispositionally anxious a person is across time and situations) and state anxiety (how anxious a person is feeling at a particular moment) as it consists of two separate sub-scales (STAI-T and STAI-S, respectively) each containing 20 items. An abnormal value of STAI was considered when ≥40 [15].

The questionnaire was sent to each included woman in the days of maximum spread of COVID 19 in Italy (March 9–March 10, 2020) close to the day of the total lockdown sanctioned by the Italian government (March 9, 2020). All the women provided at the time of ultrasonographic examination written informed consent to be re-contacted, if necessary, for clinical and research purposes. The study was approved by our institutional Ethics Committee.

Results

The questionnaire was returned completely filled by 178 women (89%) within 48 h from the shipment and these women were considered for the study. Their general characteristics are reported in Table 1.

Median maternal age was 33 years (IQR 30–36 years) and most respondents were Caucasian (98.9%) and born in Italy (94.5%). The majority of respondents were employed (84.3%) and had a higher educational level (i. e., University or diploma) (87.7%).

The median gestational age at the receipt of the questionnaire was 18 weeks (IQR 15–23) and women were in the first, second and third trimester in the 17, 61 and 22% of the cases, respectively.

About the sources of information on COVID-19 64% of participants were self-documented by newspaper and television, 29% by Internet and social and only 7% by family doctors and emergency dedicated telephone numbers.

The attitude toward COVID-19 showed women’s willingness to follow government guidelines on quarantine and social distancing in 93% of the cases and fear to go to the hospital in the 75%.

About maternal concerns of the effect of infection: 37% were concerned not having enough information about the effects of COVID-19 in pregnancy, 41% not being able to carry out regular antenatal care and 22% that they had come into contact with the virus.

A fear that COVID-19 could induce fetal structural anomalies was present in 83 women (46.6% 95% confidence interval [CI] 39.4–53.9), fetal growth restriction in 116 (65.2% 95% CI 57.9–71.7) and preterm birth in 91 (51.1%; 95th CI 43.8–58.3) of women (Figure 1).

Figure 1:

Forest plot showing the prevalence (%) and 95th confidence interval of maternal fear for perinatal complications.

The median trait anxiety score (STAI-T) was 37 (IQR 20–43) and 68 women (38.2% 95% CI 31.3–45.5) showed a STAI-T score ≥40. The psychological impact of COVID-19 outbreak, measured using the S scale, revealed increased values of STAI-S scale (median 49 IQR 40–56) with a significant increase of 12 points in median values when compared to T scale (Wilcoxon signed rank test=363; p≤0.0001) (Figure 2). As a consequence, there is significant higher prevalence (77.0% 95% CI 70.1–82.5) of women that overcome the cut-off score of 40 for state of anxiety when STAI-S was applied (χ²=53.8, p≤0.0001).

Figure 2:

Box plot showing state–trait anxiety inventory (STAI-T) and STAI-S scales. Horizontal lines within boxes, boxes and whiskers represent median, interquartile range and range, respectively.

There was a positive linear correlation between STAI-T and S anxiety scores (Pearson r= 0.59; p<0.0001).

A higher educational status was associated with a significant increase in the prevalence of STAI-S values ≥40 (p=0.004) but not of STAI-T values (p=0.158) (Table 2). No significant differences in maternal age, gestational age, parity and employment status were evidenced between women with normal (<40) or abnormal (≥40) STAI-T an S scores (Table 2).

Discussion

Conclusions

Our data suggest that pregnant women have a greater psychological impact as well as higher anxiety in COVID-19 outbreak. Identify high-risk women can be important to suggest early psychological interventions and prevent some pregnancy stress-related complications.