Mental disorders among pregnant women during the COVID-19 pandemic. A cross-sectional study

ABSTRACT BACKGROUND: Pregnancy is the most important event in women’s lives and can lead to psychological lability. Several risk factors (such as disasters, events and pandemics) have been correlated with greater prevalence of mental disorders during pregnancy. OBJECTIVES: To research how pregnant women have been affected by the coronavirus disease-19 (COVID-19) pandemic process, in order to contribute to the limited literature. DESIGN AND SETTING: Cross-sectional survey study conducted at the Training and Research Hospital of the Faculty of Medicine, University of Ordu, Ordu, Turkey, from February 1 to March 1, 2021. METHODS: In total, 356 pregnant women were enrolled and completed the survey. Intention of going to hospital and the Beck anxiety, Beck depression, Beck hopelessness and Epworth sleepiness scales were applied to detect mental disorders. RESULTS: Among the participants, the anxiety, depression, hopelessness and sleepiness scores were 29.2%, 36.2%, 58.1% and 11.8%, respectively. The pregnant women stated that they avoided going to hospital in unnecessary situations by obeying the ‘stay at home’ calls, but also stated that they were afraid of the potential harmful effects of inadequate physician control. However, most of them stated that they would go to the hospital in emergencies. CONCLUSIONS: This paper illustrated the effect of the COVID-19 pandemic on the mental health of pregnant women and emphasized their high rates of anxiety, depression, hopelessness and sleepiness. Since presence of mental disorders is indirectly related to poor pregnancy outcomes, preventive strategies should be developed, especially during this pandemic process.


OBJECTIVE
The aim of this study was to investigate how pregnant women have been affected by the pandemic process, in order to contribute to the limited literature on this subject.

METHODS
This descriptive cross-sectional survey study was conducted between February 1 and March 1, 2021. Over this period, the numbers of cases of COVID-19 infection were increasing rapidly in the city of Ordu, which is the third largest city by population in the Black Sea region of Turkey. Furthermore, also over the period of the survey, this city and its province (Altınordu) ranked highest in the weekly number of cases per 100,000 population in Turkey. 11 The study population consisted of pregnant women who were In our study, data from 356 pregnant women who completed the survey questionnaire were analyzed. Patients diagnosed with COVID-19 or with existing psychiatric diseases were excluded from the study.
The first part of the survey included ten questions that aimed to collect data about the participant's demographic characteristics and pregnancy conditions. These ten questions asked about their age, number of pregnancies, pregnancy trimester, work, body mass index, education, marital status, presence of chronic disease, smoking and any close contact with COVID-19-infected patients.
The second part of the survey consisted of the "intention of going to hospital" scale. This scale, consisting of nine questions, was developed by Bostan. 12 The questions in this part were as fol- pants were asked to answer these questions by selecting one of five options that were scored from zero to four. One of the questions on the intention of going to hospital scale was excluded from the analysis because it did not reach a sufficient factor load.
Lastly, in the third part of the survey, the participants answered questions on the Beck anxiety scale, 13 Beck depression scale, 14 Beck hopelessness scale, 15 and Epworth sleepiness scale. 16 Details of the questionnaire are presented in Table 3. The Beck anxiety scale was developed in 1988 and consists of 21 items on Likert scales ranging from zero to three, and with raw scores ranging from 0 to 63.
The Beck depression scale was first introduced in 1961 and contains questions on 21 symptoms and attitudes. The questions receive ratings from zero to three to reflect the intensity of symptoms or attitudes, and this gives rise to a score that can range from 0 to 63. A total score of less than 9 depicts minimal depression; a score of 10-18, mild depression; a score of 19-29, moderate depression; and a score of 30 or above, severe depression.
The Beck hopelessness scale was defined in 1974 and includes 10 questions. Its total score can range from 0 to 20. Scores from 0 to 3 are considered normal; 4 to 8, mild hopelessness; 9 to 14, moderate hopelessness; and greater than 15, severe hopelessness.
The Epworth sleepiness scale was initially reported in 1991 and is a self-administered questionnaire consisting of 8 questions.
Respondents are asked to rate each item on a four-point scale (0 to 3). On this scale, scores of 0-9 are evaluated as mild sleepiness and scores of 10 and above are evaluated as severe sleepiness.
The Beck and Epworth scales are widely used within in healthcare. The validity of these scales has been tested by means of confirmatory factor analysis. The validity of the "intention of going to hospital" scale was tested by means of exploratory factor analysis.
In addition, reliability analyses were performed on all the scales.
The Kaiser-Meyer-Olkin (KMO) sampling coefficient was found to be greater than 0.80 for each scale, and this was accepted as very good.
The results from the Bartlett sphericity test, which was used to evaluate the appropriateness of the scales for factor analysis, were also found to be significant (P = 0.000). According to these evaluations, the scales were found to be suitable for factor analysis. It was understood that the factor loads of all the scales were generally high and their power to explain the total variance was sufficient.
To analyze the results from the study, the Statistical Package for the Social Sciences (SPSS) software, version 26, was used (IBM Statistics, Armonk, New York, United States). The analyses were carried out using a 95% confidence interval (P = 0.05). Descriptive statistical methods and correlation analyses were used in the study.

RESULTS
In total, 356 pregnant women in Ordu were enrolled in this study. The second part of the survey consisted of eight questions on the "intention of going to hospital" scale, which are presented in Table 2. This scale was designed using a five-degree Likert scale.
For as long as the pandemic continues, the participants declared that they would not go to the hospital to visit their relatives or friends, or to have their medicine prescribed, or to have the routine tests that they had in mind (96.6%, 50.8% and 57.3% respectively).
The proportion of the patients who stated that they would not go to the hospital even when they felt mild discomfort was 60.7%.

DISCUSSION
More than one year has passed since COVID-19 was declared a pandemic. Despite this length of time, the effects of the pandemic are still felt all over the world. 17 Undoubtedly, healthcare professionals constitute the group most affected in this process. While the effect of pandemic on the healthcare sector and on healthcare workers has been the subject of many studies, the number of investigations in the literature, on its effects on the pregnant population, is limited. [18][19][20] The aim of this descriptive study was to contribute to this limited literature through investigating the effects of the pandemic process on pregnant women.
Pregnancy itself is already known to be a cause of psychological lability, and this has been shown in many studies. 5,[21][22][23] Not surprisingly, pregnant women have relatively high prevalence rates of anxiety, depression, hopelessness and sleepiness. In three different meta-analyses that compiled data on the mental status of pregnant women, the prevalences of anxiety, depression and In addition, many studies have shown that events such as natural disasters, economic crisis and pandemics adversely affect the mental health of the community. 3,27,28 It is inevitable that such events will affect pregnant women worse than the general population. 22 It has been determined that the main factors adversely affecting pregnant women's mental health and causing anxiety in pandemics have been abstention from the daily routine, the need for social distancing and decreased social support. They also expressed fears about their babies' , their families' and their own health, due to the uncertainties of the pandemic. 6 Studies on pregnancy in relation   We observed that anxiety and depression rates have been found to be related to each other in many studies. 6,20,23 In our study, 36.2% of the participants presented depression (in 10.7%, it was moderate or severe). As expected, anxiety related to COVID-19 infection also led to depressive symptoms in the pregnant population.
In a cross-sectional study investigating sleep quality among pregnant women, sufficient sleep duration was defined as sleeping 7-9 h/day. 30 In some studies, it has been shown that the proportion of pregnant women with poor sleep quality (for a variety of reasons) was between 38.8% and 82.6%. [31][32][33] In our study, the rate of sleepiness was found to be lower than in the literature (11.8%).
We attributed this low rate to the Epworth sleep scale that we used in the survey, because this scale evaluated sleepiness in only two stages, unlike the ones used in the literature. In studies on pregnant women, high anxiety level, low social support and insufficient partner support were found to be associated with low sleep quality. Therefore, it is very important to provide the necessary social and partner support in order to protect pregnant women from the psychologically destructive effects of the pandemic. With this support, situations such as social isolation and postpartum depression can be prevented, and a healthy partner relationship and adequate baby care can be provided after delivery. 34,35 Studies conducting subgroup analysis have shown that multigravid pregnant women were more affected by the COVID-19 pandemic. Multigravid women have to struggle with several challenges, such as increased financial responsibilities and having an additional child. Moreover, in these studies, it was observed that greater anxiety was detected in the first and third trimesters, possibly due to hormonal changes and fear of delivery. 36,37 Many studies have suggested that mental disorders have a more severe course in the prenatal and postnatal periods and that they have lasting negative effects on mothers, fetuses and children.
The adverse prenatal outcomes include preeclampsia, gestational hypertension, gestational diabetes, miscarriage, intrauterine growth restriction and low birth weight. 7-10 Emotional, behavioral and cognitive problems have been found to be more common among postnatal mothers. Additionally, in further follow-up, changes to brain structures and functions were observed in their children. [38][39] Some limitations of our study should be noted. Although we found high rates of anxiety, depression, hopelessness and sleepiness among pregnant women in the COVID-19 pandemic, we could not make any comparison with previous times since we did not have pre-pandemic data. In addition, we did not question the main reasons for increases in these parameters during the pandemic period in our survey. Our study provides information about the general population of pregnant woman because we were unable to clearly distinguish any group at higher risk among these pregnant women, through subgroup analyses, due to the limited number of patients and the cross-sectional structure of this survey.

CONCLUSION
This study revealed the effect of the COVID-19 pandemic on the mental health of pregnant women and highlighted the high prevalence rates of anxiety, depression, hopelessness and sleepiness among this population. Since the increased prevalence of mental disorders consequent to the pandemic is indirectly associated with poor pregnancy outcomes, the necessary support needs to be provided for this group of patients. This study has helped to emphasize the necessity of interventions that can be taken, especially during the pandemic process. Further studies could broaden the knowledge of the mental effects of COVID-19 among pregnant women.