key: cord-307516-5r5h1z1o authors: Kahyaoglu Sut, Hatice; Kucukkaya, Burcu title: Anxiety, depression, and related factors in pregnant women during the COVID‐19 pandemic in Turkey: A web‐based cross‐sectional study date: 2020-09-28 journal: Perspect Psychiatr Care DOI: 10.1111/ppc.12627 sha: doc_id: 307516 cord_uid: 5r5h1z1o PURPOSE: This study aimed to assess the prevalence of anxiety and depression and related factors in pregnant women during the coronavirus disease 2019 (COVID‐19) pandemic. DESIGN AND METHODS: This cross‐sectional study was conducted on 403 pregnant women using a web‐based survey. The hospital anxiety and depression scale was used to measure anxiety and depression. FINDINGS: The prevalence of anxiety and depression was 64.5% and 56.3%, respectively. Working status, physical activity status, discomfort with hospital visits, having information about COVID‐19, and being informed by healthcare workers about COVID‐19 were factors related to anxiety (p < .05). Education level, physical activity status, discomfort with hospital visits, and having information about COVID‐19 were factors related to depression (p < .05). PRACTICE IMPLICATIONS: The aforementioned factors should be considered for reducing anxiety and depressive symptoms during pregnancy. prenatal check-ups and ultrasound scans. 12 In a previous study, 64.3% of women were found to experience a psychological change during pregnancy. 13 More than half of pregnant women in China were found to have moderate psychological symptoms. 14 Uncertainty about the duration of the COVID-19 pandemic increases the anxiety level of pregnant women. 15 However, there is no definitive information on the effect of COVID-19 on the mental health of pregnant women. 16 Pregnant women are concerned about the harmful effects of the virus on their own health and fetal health (Ng et al. 35 ). In China, pregnant women reported an increase in their anxiety due to the thought that COVID-19 would be transmitted to their fetus by vertical transmission. 2 In Canada, perinatal loss was reported to be the most common concern. 17 Moreover, in Ireland, pregnant women reported being excessively concerned about their unborn babies, 18 while in Italy, they reported having high anxiety regarding vertical transmission. 16 Stress-related anxiety during pregnancy may result in fetal death or fetal abnormalities. 16 Pregnant women are more likely to develop anxiety and depression during the COVID-19 pandemic 6 ; the prevalence of anxiety in pregnant women has been reported to range from 63% to 68%. [16] [17] [18] In addition, higher levels of anxiety and depression have been reported in pregnant women than in nonpregnant women. 6, 19 A high level of anxiety in pregnant women during the pandemic may negatively affect pregnancy and fetal outcomes. 11 Increased anxiety during pregnancy also leads to a high risk of postpartum depression or other mood disorders. 20 In developed countries, 10% of pregnant women experience depression and the number of antidepressants prescribed to pregnant women has increased in the last decade. 21 Providing isolation, communication, and psychological assistance during the COVID-19 pandemic is particularly beneficial for preventing negative impacts on the mental health of pregnant women and on the fetus. 2 The impact of COVID-19 on the mental health of pregnant women should be evaluated. 22 Being aware of and connecting with support systems for perinatal mental health protects the mental health of pregnant women. 23 Assessment of the effects of COVID-19 on anxiety and depression during pregnancy is important to determine the role of support systems in pregnancy and the possible impacts on the postpartum period. The present study aimed to examine the level and prevalence of anxiety and depression and related factors in pregnant women during the COVID-19 pandemic. This cross-sectional study was conducted using a web-based online survey via Facebook pregnancy groups in June and July 2020. The study was conducted on 403 pregnant women who were over 18 years old, were willing to complete an online survey, had no history of psychological disorders, and did not use any psychiatric medication. Pregnant women from the Facebook pregnancy groups were invited to participate in the study via an online survey link. They were informed about the study on the first page of the online survey. The survey contained three parts: the first part contained questions on sociodemographic and clinical characteristics, the second part contained questions on the knowledge and attitude about COVID-19, and the third part contained 14 items of the hospital anxiety and depression scale (HADS) for evaluating psychological distress. The HADS consists of 14 items and two subscales 24 and has been validated previously. 25 It was used to evaluate the anxiety and depressive symptoms in pregnant women in the present study. HADSanxiety and HADS-depression scores were derived by summing the subscale items. Higher HADS-anxiety and HADS-depression scores indicate higher anxiety and depression levels, respectively. Pregnant women with HADS-anxiety scores ≥8 were classified as having anxiety, while those with HADS-depression scores ≥8 were classified as having depression. The Cronbach's alpha coefficient of the HADS was found to be 0.94, indicating good reliability. The present study was approved by the Trakya University Scientific Research Ethics Committee (2020-268). An electronic informed consent was presented on the first page of the online survey. The participants were electronically informed on the first page of the survey that they were volunteering to participate and that they could withdraw from the survey at any time. Normality of the numeric variables was tested using the Shapiro-Wilk test. Numeric results are presented as the mean ± standard deviation for normally distributed data and median Table 1 . The mean age of the participants was 28.2 ± 4.5 years (range, 18-41 years), and their mean gestational week was 27.3 ± 8.8. In total, 68% of the participants reported that they experienced discomfort with visiting the hospital or doctor for their pregnancy followup visits, while 79.2% reported that they regularly visited the hospital for their pregnancy follow-up visits during the COVID-19 pandemic. Almost all the pregnant women (95.8%) and healthcare workers (94.3%) reported that they followed the isolation rules during the pregnancy follow-up visits. Moreover, 57.1% of the participants reported that they had information about the effects of COVID-19 on pregnancy; however, 32 .8% reported that they were informed by their doctor/nurse/midwife about the effect of COVID-19 on maternal and fetal health ( Table 2 ). The average HADS-anxiety score of the participants was 9.6 ± 6.4, and their average HADS-dDepression score was 8.7 ± 5.2. The prevalence of anxiety and depression in pregnant women during the COVID-19 pandemic was 64.5% and 56.3%, respectively (Table 3 ). HADS-anxiety and HADS-depression scores were significantly higher in pregnant women whose education level was less than 9 years, who were not working, who were not engaging in physical activity, and who were smokers (p < .05 for all). In addition, pregnant women who had a chronic illness had higher HADS-anxiety (p = .013) and HADS-depression (p = .074) scores (Table 4) . HADS-anxiety and HADS-depression scores were significantly higher in pregnant women who experienced discomfort with visiting the hospital or doctor for follow-up visits (Q1), who did not go for follow-up visits regularly (Q2), and who did not follow the isolation rules (Q3). Similarly, these scores were significantly higher in pregnant women when the isolation rules were not followed by the healthcare workers during pregnancy follow-up visits (Q4). In addition, HADS-anxiety and HADS-depression scores were significantly higher in pregnant women who had no information about the effects of COVID-19 on pregnancy (Q5) and who were not informed by healthcare workers about the effects (Q6) ( Table 5 ). Of the 11 probable factors related to the development of anxiety that were entered into multivariate logistic regression analysis, five factors were found to be significant (Table 6 and Figure 1 ). Four significantly independent risk factors were determined to be related to the development of depression (Table 6 and Figure 2 ). The risk of depression in pregnant women whose education level was less than 9 years was 2.76 times higher (95% CI: 1.22-6.28) than that in pregnant women whose education level was 9 years or above (p = .015). In addition, the risk of depression in pregnant women who did not engage in regular physical activity was 2.36 times (95% CI: depression in pregnant women has significantly increased after the spread of COVID-19 throughout the world. The risk of anxiety and depression in pregnant women with low education levels was found to be higher in the present study. Similarly, low education levels have been found to be associated with a high prevalence of anxiety and depression in Chinese pregnant women. 28 Furthermore, the risk of psychological abnormality has been reported to be higher in pregnant women with less than high school education. 6 These findings indicate that education is an important factor related to the development of anxiety and depression during pregnancy and that pregnant women with low education levels have a high risk of developing anxiety and depressive symptoms. Nanjundaswamy et al. 12 found that approximately 35% of pregnant women in India have job-related concerns. A significant positive relationship has been reported between unemployment and prenatal depression in pregnant women (Ma et al. 26 ). Moreover, being a housewife (i.e., being unemployed) during pregnancy has been found to be a risk factor related to the development of anxiety and depression. 29 In accordance with previous findings, the present study from infected pregnant women to fetuses. [6] [7] [8] 36 The irrational use of social media to inform about the effects of COVID-19 increases the risk of anxiety and fear of getting infected. 34 Most pregnant women want to learn about personal protection, susceptibility to COVID-19, and intrauterine transmission. 8 There is an urgent need for healthcare workers to manage the psy- The present study has several limitations. One of the limitations is its cross-sectional design. The investigation of causal relationships is more difficult with a cross-sectional design than with a longitudinal design. Another limitation is that participation in the study was voluntary; therefore, there is the possibility of selection bias. 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