|Year : 2022 | Volume
| Issue : 4 | Page : 269-275
Mental health and fear of COVID-19 in Iranian pregnant women: A multi-center study
Samaneh Torkian1, Fatemeh Torkian2, Sahebjan Torkian3, Fatemeh Mokhtari2
1 Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
2 Department of Midwifery, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Health Education and Health Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||02-Dec-2021|
|Date of Decision||29-Oct-2022|
|Date of Acceptance||29-Oct-2022|
|Date of Web Publication||18-Jan-2023|
Department of Midwifery, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: The new coronavirus (COVID-19) pandemic has extensive psychological effects on pregnant women. Objectives: The aim of this study was to assess mental health, fear of COVID-19, and their association among pregnant women. Methods: This cross-sectional study was conducted on 607 pregnant women in Isfahan, Iran, from September 26 to December 20, 2020. The pregnant women were randomly selected from health centers affiliated with Isfahan University of Medical Sciences using a two-stage cluster sampling. A three-part web-based questionnaire (i.e., a demographic questionnaire, the Fear of COVID-19 Scale, and the General Health Questionnaire) was used to collect data. Chi-square test, independent-samples t-test, and logistic regression analysis were used for data analysis. Results: Most participants (73%) had a high level of fear of COVID-19, while 11% had a history of COVID-19 infection. In the final model, poor financial status (odds ratio [OR] = 3.06, 95% confidence interval [CI]: 1.32–7.10), COVID-19 infection (OR = 2.25, 95% CI: 1.22–4.16), history of mental disorders (OR = 10.11, 95% CI: 2.44–41.75), and number of pregnancies (OR = 2.59, 95% CI: 1.39–4.81) were associated with a significant increase in the chance of mental health disorder. A high COVID-19 fear score resulted in a 29% increase in mental health disorders, although this increase was not statistically significant. Conclusion: The prevalence of fear of COVID-19 was high among pregnant women. Poor financial status, number of pregnancies, history of COVID-19 infection, and a history of mental problems were associated with an increased risk of mental health disorders in pregnant women.
Keywords: COVID-19, Fear, Iran, Mental health, Pregnant women
|How to cite this article:|
Torkian S, Torkian F, Torkian S, Mokhtari F. Mental health and fear of COVID-19 in Iranian pregnant women: A multi-center study. Nurs Midwifery Stud 2022;11:269-75
|How to cite this URL:|
Torkian S, Torkian F, Torkian S, Mokhtari F. Mental health and fear of COVID-19 in Iranian pregnant women: A multi-center study. Nurs Midwifery Stud [serial online] 2022 [cited 2023 Mar 24];11:269-75. Available from: https://www.nmsjournal.com/text.asp?2022/11/4/269/368007
| Introduction|| |
In late December 2019, a new virus from the coronavirus family (COVID-19) emerged and spread rapidly around the world. Pregnant women are among the most vulnerable groups during the COVID-19 pandemic. They are more susceptible to infection and are at increased risk for severe complications due to their naturally suppressed immune system.
Pregnancy is a life-changing period associated with intense emotions and mental health disorders. About 12% of women experience depression and up to 22% suffer from severe anxiety in late pregnancy., A study reported that the COVID-19 pandemic has short- and long-term effects on the mental health of pregnant mothers. During the pandemic, preventive measures such as quarantine, physical distance, remote consultation with physicians and healthcare professionals, and failure to receive enough prenatal care heightened the concern of pregnant mothers. The increased stress in pregnant women can cause serious complications such as preeclampsia, hypotension, severe pregnancy-related nausea, and vomiting. It may even result in preterm birth with, low birth weight and low APGAR in the newborn. Pregnant mothers have been shown to be very concerned about their health and the fetus during the COVID-19 pandemic. The COVID-19 pandemic has also increased the prevalence of mental disorders in pregnant women and severely affected their quality of life.,,, Research has also shown that a pregnant woman's mental health affects not only her health but also the health of the baby and family members. However, none of the studies have examined the association between fear of COVID-19 and the mental health of pregnant women., Therefore, this study was conducted to fill this gap.
The aim of this study was to examine the mental health of pregnant women, its risk factors, and its association with the fear of COVID-19.
| Methods|| |
Design and participants
This cross-sectional study was conducted on 607 pregnant women in Isfahan city, Iran, from September 26 to December 20, 2020. The sample size was calculated based on the results of a previous study that assessed the general health of people during the COVID-19 pandemic and the mean score of the subjects was reported to be 19.02 ± 2.08. Then, considering a type one error of 0.05, a mean of 19.02 and a standard deviation of 2.08, a measurement error (d) of 0.2, and the design effect of 1.5, the minimum sample size was calculated to be 606. However, considering a possible dropout of 5% (DR), the total sample size was increased to 638 (Nadjusted = n (606)/(1-DR)., First, 18 health centers affiliated with Isfahan University of Medical Sciences were randomly selected based on the √n/2 formula. Then, simple random sampling was conducted to recruit pregnant women from each health center.
Inclusion criteria were pregnancy, ability to read and write in Persian, willingness to participate in the study, and having access to the Internet. Initially, the telephone number and national code of all pregnant women were obtained from the local health center. The national codes were then used to create a sampling frame, and subjects were randomly selected from the list. Those with inclusion criteria were contacted and invited to participate in the study.
Data collection instruments
A demographic questionnaire, the General Health Questionnaire (GHQ-28), and the Fear of COVID-19 Scale (FCV-19S) were used to collect data. Demographic questions included questions on age (year), education level (academic degree, high school, primary school), having a job (yes/no), financial status (good, moderate, poor), COVID-19 infection in the past year (yes/no), having COVID-19 infection in the family in the past year (yes/no), history of mental diseases (yes/no), number of pregnancies (one, two, three, and more than three), history of infertility (yes/no), assisted pregnancy (yes/no), the age of pregnancy (first trimester, second trimester, third trimester), hospitalization during pregnancy (yes/no), bed rest (yes/no), a noncommunicable disease (NCD) in pregnancy such as preeclampsia, eclampsia, gestational diabetes and hypertension (yes/no), a chronic NCD before pregnancy such as diabetes, hypertension, and heart disease (yes/no).
The GHQ-28 includes 28 items in four subscales, namely physical symptoms, anxiety and sleep disorders, social dysfunction, and depression. All items are rated on a 4-point Likert scale ranging from 0 to 3. The score of each subscale ranges from 0 to 21 and the total score ranges between 0 and 84. A lower score indicates better mental health. Individuals with a total score of 23 or less are considered as healthy, whereas those with a score of ≥24 are considered to have a mental disorder. Rashidi et al. confirmed the validity and reliability of the Persian translation of the GHQ-28 and its Cronbach's alpha was 0.88.
FCV-19S is a seven-item scale, and all items are rated on a 5-point Likert scale ranging from 1: “strongly disagree” to 5: “strongly agree.” The total score of the FCV range from 7 to 35, with higher scores indicating greater fear of COVID-19. The validity and reliability of the FCV-19S have already been confirmed in Iran. A score ≥16.5 indicates greater fear of COVID-19. The Cronbach's alpha of the GHQ-28 and the FCV-19S in this study were 0.89 and 0.71, respectively.
The link to the questionnaire was sent to pregnant women via short message service, WhatsApp, or Telegram messengers. A total of 607 subjects completed the study.
The study protocol was approved by the Research Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran (approval code: IR.MUI.MED.REC.1399.488). The purposes of the study were explained to all pregnant women. Participation in the study was voluntary, data were managed confidentially, and results were reported anonymously. All participants signed a written informed consent before contributing to the study.
Descriptive analyses, including frequency, percentage, mean, and standard deviation, were calculated to describe the variables. The Chi-square test was used to compare the categorical variables. The independent samples t-test was used to compare the mean scores between the subgroups of the participants. Logistic regression analysis was used to investigate the relationship between GHQ-28 and FCV-19S scores and other variables. First, all independent variables were entered into univariate logistic regression models using the Enter method. Then, all variables with a P < 0.2 were entered into the multivariable logistic regression model using the forward method. Odds ratio (OR), adjusted odds ratio, and 95% confidence interval (95% CI) were reported (AOR). P < 0.05 were considered statistically significant. All analyses were conducted using the SPSS software version 16 (SPSS Inc., Chicago, IL, USA).
| Results|| |
The mean age of the pregnant women was 28.66 ± 5.41 years. Most of them had academic and high school education (87.2%), were in the second and third trimesters of pregnancy (88.1%), and had their first pregnancy (45.5%), 30% reported pregnancy-related diseases, and 11.5% had a history of COVID-19 infection. However, 73.3% of them reported a high level of fear of COVID-19 [Table 1]. In the univariable models, poor financial status, COVID-19 infection, history of mental disorders, number of pregnancies, and having NCD before pregnancy were associated with general health disorders and entered into the multivariable model. A high FCV-19S score resulted in a 29% increase in general health disorders, but this was not statistically significant [Table 2].
|Table 2: Univariable and multivariable logistic regression analysis for the association between general health with fear of COVID-19 and other variables|
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In the multivariable model, poor financial status (OR = 3.06, 95% CI: 1.32–7.10), COVID-19 infection (OR = 2.25, 95% CI: 1.22–4.16), a history of mental disorder (OR = 10.11, 95% CI: 2.44–41.75), and the number of pregnancies were associated with a significant increase in odds of mental health disorders. Furthermore, the second (OR = 1.87, 95% CI: 1.11-3.14) and third pregnancy (OR = 2.59, 95% CI: 1.39–4.81) were associated with a significant increase in the chance of general health disorders [Table 2].
| Discussion|| |
About one-sixth of our participants had a mental disorder. Increased odds of having a mental disorder were associated with poor financial status, COVID-19 infection, a history of mental health problems, number of pregnancies, and having NCD before pregnancy, but none of these variables were associated with high FCV-19S scores. Mental health during pregnancy is a serious public health issue. Contrary to our results, a study in China reported that during the COVID-19 pandemic, pregnant women had less depression, anxiety, insomnia, and posttraumatic stress disorder symptoms than nonpregnant women. Despite the controversies found between the two studies, as the pandemic progresses, pregnant women may experience more anxiety and depression than nonpregnant ones, and pregnancy becomes a risk factor for the development of psychopathological disorders. A study in China found that pregnant women are more prone to depression during the outbreak of COVID-19 disease. The stress caused by COVID-19 may even lead some mothers to request early termination of pregnancy and cesarean section. A study in Iran found that 32.7%, 32.7%, and 43.9% of pregnant women experienced depression, stress, and anxiety symptoms during the COVID-19 pandemic, respectively. A study in Italy also reported that 21.7% and 10.2% of pregnant women experienced anxiety and stress during the COVID-19 pandemic. However, the prevalence of mental disorders during the pandemic was higher among our participants. The prevailing culture, and the type, and the quality of health services in different communities, may justify the differences observed in the prevalence of mental disorders between studies. Nonetheless, the instruments used in the different studies may also affect the reported prevalence.
About three-quarters of our participants reported high levels of fear of COVID-19. Another study from Iran also reported that pregnant women have high levels of fear of COVID-19, which negatively affects their quality of life. Studies in Japan, Pakistan, and Canada also reported that pregnant women suffer from moderate to high levels of fear and concern during the COVID-19 pandemic. A study also suggested that sociodemographic variables, health conditions, and obstetric factors may contribute to the increased fear of COVID-19 and are associated with adverse pregnancy outcomes. Fear is an unpleasant emotional state caused by the perception of threatening stimuli such as COVID-19 epidemics. High levels of fear may negatively affect people's behavior. Therefore, high levels of fear of COVID-19 may cause pregnant women to be less likely to attend routine checkups at health centers, which in turn may negatively affect their health and pregnancy outcomes. In this study, poor financial status, a history of getting COVID-19 infection, a history of mental health problems, and the number of pregnancies were associated with mental health disorders. In line with our results, a study showed that financial problems, poor support from the spouse, previous psychiatric problems, chronic medical disorders, and poor prenatal services were the potential risk factors for prenatal depressive disorders. A former study in Iran also reported that childbirth history, pregnancy problems, history of COVID-19 in family members, concern for maternal and neonatal consequences, and receiving care could predict anxiety and perceived stress scores in pregnant women.
In this study, second and third pregnancies were associated with a significantly higher risk of general health problems than first pregnancies, although the association was not statistically significant among those with more than three pregnancies. However, some studies reported that those with a first pregnancy and no childbirth experience had more stress than those with multiple pregnancies., Such differences may be attributed to differences in the prevalence of the disease in different societies or cultural differences between societies.
Only women who were literate and had access to the Internet were included in this study. Furthermore, due to the cross-sectional nature of the study, the reported statistical associations cannot demonstrate causality. More rigorous study designs, such as cohort studies, might be helpful to further investigate the causal relationships. However, the random and multicenter sampling methods were among the strengths of this study and increased the external validity of the results.
| Conclusion|| |
In this study, pregnant women presented a high rate of fear of COVID-19. Furthermore, poor financial status, number of pregnancies, history of COVID-19 infection, and a history of mental problems were associated with an increased risk of mental disorders in pregnant women but not with the fear of COVID-19. Considering the prevalence of fear and mental health disorders in pregnant women, it is recommended that health care providers and health policy makers develop and implement educational and counseling programs to improve the mental health of pregnant women during the COVID-19 pandemic.
The authors would like to acknowledge the research deputy of the Isfahan University of Medical Sciences, and all women who participated in this study.
Financial support and sponsorship
The study was funded by Isfahan University of Medical Sciences, Isfahan, Iran with research code (No: 199222).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Torkian S, Akhlaghi E, Khosravi V, Etesami R, Ahmadi A, Khanjani N, et al.
Social support and adjustment during COVID-19 epidemic: A community-based study in Iran. Iran J Psychiatry Behav Sci 2020;14:e108503.
Wu Y, Zhang C, Liu H, Duan C, Li C, Fan J, et al.
Perinatal depressive and anxiety symptoms of pregnant women during the coronavirus disease 2019 outbreak in China. Am J Obstet Gynecol 2020;223:240.e1-240.e9.
Kourtis AP, Read JS, Jamieson DJ. Pregnancy and infection. N Engl J Med 2014;370:2211-8.
Ceulemans M, Hompes T, Foulon V. Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic: A call for action. Int J Gynaecol Obstet 2020;151:146-7.
Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstet Gynecol 2011;118:1056-63.
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.
Thapa SB, Mainali A, Schwank SE, Acharya G. Maternal mental health in the time of the COVID-19 pandemic. Acta Obstet Gynecol Scand 2020;99:817-8.
Rashidi Fakari F, Simbar M. Coronavirus pandemic and worries during pregnancy; a letter to editor. Arch Acad Emerg Med 2020;8:e21.
Abedzadeh-Kalahroudi M, Karimian Z, Nasiri S, Khorshidifard M. Anxiety and perceived stress of pregnant women towards COVID-19 disease and its related factors in Kashan (2020). Iran J Obstet Gynecol Infertil 2021;24:8-18.
Jiang H, Jin L, Qian X, Xiong X, La X, Chen W, 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.
Mirzaei N, Jahanian Sadatmahalleh S, Bahri Khomami M, Moini A, Kazemnejad A. Sexual function, mental health, and quality of life under strain of COVID-19 pandemic in Iranian pregnant and lactating women: A comparative cross-sectional study. Health Qual Life Outcomes 2021;19:66.
Salehi L, Rahimzadeh M, Molaei E, Zaheri H, Esmaelzadeh-Saeieh S. The relationship among fear and anxiety of COVID-19, pregnancy experience, and mental health disorder in pregnant women: A structural equation model. Brain Behav 2020;10:e01835.
Kotabagi P, Fortune L, Essien S, Nauta M, Yoong W. Anxiety and depression levels among pregnant women with COVID-19. Acta Obstet Gynecol Scand 2020;99:953-4.
Corbett GA, Milne SJ, Hehir MP, Lindow SW, O'connell MP. Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic. Eur J Obstet Gynecol Reprod Biol 2020;249:96-7.
Alizadeh Fard S, Saffarinia M. The prediction of mental health based on the anxiety and the social cohesion that caused by coronavirus. Quart Soc Psychol Res 2020;9:129-41.
Gupta KK, Attri JP, Singh A, Kaur H, Kaur G. Basic concepts for sample size calculation: Critical step for any clinical trials! Saudi J Anaesth 2016;10:328-31.
Ben-Shlomo Y, Brookes S, Hickman M. Epidemiology, Evidence-Based Medicine and Public Health. 6th
ed. East Sussex, Wiley Blackwell: John Wiley & Sons; 2013.
Kodinariya TM, Makwana PR. Review on determining number of cluster in K-Means clustering. Int J Adv Res Computer Sci Manage Stud 2013;1:90-5.
Hjelle EG, Bragstad LK, Zucknick M, Kirkevold M, Thommessen B, Sveen U. The General Health Questionnaire-28 (GHQ-28) as an outcome measurement in a randomized controlled trial in a Norwegian stroke population. BMC Psychol 2019;7:18.
Rashidi MA, Pournajaf A, Kazemy M, Kaikhavani S. Evaluating general health status using Goldberg's general health questionnaire among the staff of Ilam university of medical sciences in 2015. J Ilam Univ Med Sci 2018;26:16-26.
Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The fear of COVID-19 scale: Development and initial validation. Int J Ment Health Addict 2022;20:1537-45.
Nikopoulou VA, Holeva V, Parlapani E, Karamouzi P, Voitsidis P, Porfyri GN, et al.
Mental health screening for COVID-19: A proposed cutoff score for the Greek version of the fear of COVID-19 scale (FCV-19S). Int J Ment Health Addict 2022;20:907-20.
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;35:205-11.
Zhou Y, Shi H, Liu Z, Peng S, Wang R, Qi L, et al.
The prevalence of psychiatric symptoms of pregnant and non-pregnant women during the COVID-19 epidemic. Transl Psychiatry 2020;10:319.
López-Morales H, Del Valle MV, Canet-Juric L, Andrés ML, Galli JI, Poó F, et al.
Mental health of pregnant women during the COVID-19 pandemic: A longitudinal study. Psychiatry Res 2021;295:113567.
Wu Y-T, Zhang C, Liu H, Duan C, Li C, Fan J-X, et al.
Perinatal depressive and anxiety symptoms of pregnant women during the coronavirus disease 2019 outbreak in China. Am J Obstet Gynecol 2020;223:240.e1-240.e9.
Effati-Daryani F, Zarei S, Mohammadi A, Hemmati E, Ghasemi Yngyknd S, Mirghafourvand M. Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC Psychol 2020;8:99.
Ravaldi C, Ricca V, Wilson A, Homer C, Vannacci A. Previous psychopathology predicted severe COVID-19 concern, anxiety, and PTSD symptoms in pregnant women during “lockdown” in Italy. Arch Womens Ment Health 2020;23:783-6.
Naghizadeh S, Mirghafourvand M. Relationship of fear of COVID-19 and pregnancy-related quality of life during the COVID-19 pandemic. Arch Psychiatr Nurs 2021;35:364-8.
Asai K, Wakashima K, Toda S, Koiwa K. Fear of novel coronavirus disease (COVID-19) among pregnant and infertile women in Japan. J Affect Disord Rep 2021;4:100104.
Nausheen S, Bhamani S, Makhdoom A, Sheikh L. Fear of COVID-19 among pregnant women in Pakistan: A cross-sectional study. Int J Commun Med Public Health 2020;7:4749.
Giesbrecht GF, Rojas L, Patel S, Kuret V, MacKinnon AL, Tomfohr-Madsen L, et al.
Fear of COVID-19, mental health, and pregnancy outcomes in the pregnancy during the COVID-19 pandemic study: Fear of COVID-19 and pregnancy outcomes. J Affect Disord 2022;299:483-91.
Pakpour AH, Griffiths MD. The fear of COVID-19 and its role in preventive behaviors. J Concurrent Disord 2020;2:58-63.
Hantoushzadeh S, Bagheri M, Amjadi MA, Farahani MF, Haghollahi F. Experiences of health care providers on pregnancy and childbirth care during the COVID-19 pandemic in Iran: A phenomenological study. BMC Pregnancy Childbirth 2021;21:670.
Zegeye A, Alebel A, Gebrie A, Tesfaye B, Belay YA, Adane F, et al.
Prevalence and determinants of antenatal depression among pregnant women in Ethiopia: A systematic review and meta-analysis. BMC Pregnancy Childbirth 2018;18:462.
[Table 1], [Table 2]