key: cord-0706815-6hzk69k9
authors: BACHANI, Dr. Sumitra; SAHOO, Dr. Sushree Monika; NAGENDRAPPA, Dr. Sachin; DABRAL, Dr. Anjali; CHANDRA, Dr. Prabha
title: Anxiety and Depression among women with COVID 19 infection during childbirth – Experience from a tertiary care academic center
date: 2021-11-20
journal: AJOG Glob Rep
DOI: 10.1016/j.xagr.2021.100033
sha: e39f747038b3786c4c9d89870b8c1a4c76350c75
doc_id: 706815
cord_uid: 6hzk69k9

Background: Pregnancy and postpartum are vulnerable periods for mental health problems and distress. Studies conducted worldwide have highlighted the role of the Corona Virus Disease-19(COVID-19) pandemic in adding to rates of depression and anxiety in the perinatal period. However, there are very few reports on mothers who were identified as having COVID-19 infection at the time of childbirth. Objective(s): Our study aimed to find the prevalence of depression and anxiety among pregnant women admitted for labor who tested positive for COVID 19 infection. To study the association of various sociodemographic, social support, obstetric factors as well as that of COVID 19 related worries to depression and anxiety. Study Design: The study was conducted at the obstetrics inpatient setting in a public hospital in New Delhi which had a separate designated COVID-19 block. Pregnant and postpartum women >18 years of age, who were admitted to the COVID 19 maternity ward for delivery were included for this study. Women were interviewed within the first week of admission and after 6-8 weeks of childbirth. Sociodemographic and obstetric details as well as COVID-19 related worries and concerns were assessed. Depression and anxiety were assessed using the Patient Health Questionnaire 9(PHQ-9)and Generalized Anxiety Disorder (GAD-7) questionnaire respectively. Statistical analysis:The normally distributed variables are expressed as mean ± standard deviation and continuous variables with skewed distribution as median (interquartile range). Categorical data presented as proportions categorical variables were compared using the Chi-square test/Fischer's exact test. All tests are two-sided with a significance level of 5%. Data were analyzed using SPSS software Version 24. Rates of depression and anxiety were calculated and univariate analysis was done to identify factors associated with moderate and severe anxiety and depression, using various socio-demographic and obstetric variables, the total COVID Anxiety Scale scores, social support score. Results: The mean age of the women was 26.86±4.31 years. Of the 243 women assessed using the PHQ 9, 168(69.13%) had mild depressive disorder, and 29(11.3%) had moderate depressive disorder. Of 187 women who were assessed at the 6 weeks follow up, 31(16.57%) had minimal, 131(70.05%) mild depression and 25 (13.36%) had moderate depression. Mild anxiety was seen in 121(49.79%) and 13 (5.34%), had moderate anxiety symptoms. Women reported several worries especially about stigma of COVID 19 infection, support for infant care and access to infant health services. Conclusions: Screening for common mental illnesses with timely identification of associated risk factors should be done with liaison between obstetricians and mental health professionals. Obstetricians can address and reassure pregnant women regarding concerns about contracting the infection, worries about possible effects of COVID-19 on the fetus and newborn and concerns about future consultations. In case the worries are out of proportion and necessitate intervention by mental health professional's referral services should be made available. Hence identifying and addressing the mental health concerns will help to provide the optimum perinatal care during the pandemic.

The Corona Virus Disease 2019(COVID-19) pandemic posed major challenges for pregnant and postpartum women the world over through direct and indirect consequences. The direct consequences included the infection risk on the mother, risk of vertical transmission, preterm birth, maternal and fetal complications, and indirect consequences included an increase in stress levels, anxiety, and depression 1,2 and a higher risk for intimate partner violence 3, 4 . Women in the perinatal period faced difficulties due to isolation, quarantine, changes in health care policies and infrastructures resulted in a reduction in hospital visits for antenatal or postnatal care [5] [6] [7] . Women especially worried about testing protocols, inconsistent breastfeeding policies, lack of information and not allowing the caregiver's presence during labor. Associated economic stressors due to loss of their own jobs or jobs of partners, added additional burden 8 .

In India, first case of COVID-19 was detected on 30 th January 2020. One of the worst affected city was the national capital region of Delhi.

On 2 nd March 2020 New Delhi recorded its first case of COVID-19. During the 1 st wave of COVID-19 pandemic in New Delhi, cases started rising gradually by May 2020 with 3900 new cases per day, by the end of June 2020 and 4430 cases per day by mid September 2020 .The peak total positivity rate of 23.28% was in mid of July 2020, which reduced gradually to 6.33% in September 2020. However there was a spike in positivity rate in November 2020 i.e, 15.33% before reducing to 0.44% in Jan 2021 and 140 cases per day were recorded by end of January 2021 9 .Lockdown was implemented on 23 rd March 2020, apart from essential and emergency services everything was shut down including travel and outpatient departments in hospitals.

These rates meant that many women who were pregnant and postpartum during this period had to handle the stress of lockdowns and restrictions. Several studies have shown that there was an increase in anxiety and depression in the initial days of the pandemic in women in their perinatal period which gradually reduced over a period of time 10 . In Low and Middle Income Countries(LAMIC) situations the problems pregnant and postpartum women faced were compounded even further due to difficulties in self-isolation, living in a crowded household with an affected person, limited access to goods or services, and to routine or emergency health such as transport during labor and lack of social care(2).

In India, where the birth rate is 17.59 per 1000 people in the year 2020 11 and according to UNICEF 67,385 babies are born every day 12 , the lockdown in March 2020 and the issues related to the pandemic thereafter were quite challenging. Various precautionary measures like quarantine, social distancing, and containment strategies were implemented during the country-wide lockdown. The majority of tertiary care hospitals in the national capital region were converted into COVID-only facilities. Unexpected challenges of mass labor immigration, disruption of transport services, closure of local private health facilities resulted in antenatal women being received in an advanced stage of labor and other complications in the COVID designated hospitals.

The pandemic has therefore added to factors that might cause emotional distress in an already vulnerable period. Research studies on anxiety and depression among women during the COVID 19 pandemic have found varying rates of depression and anxiety based on the time of the study concerning the pandemic, the trimester of pregnancy, and the assessment methods 13, 14 .A review of studies on the impact of COVID-19 on women during pregnancy and the postpartum period indicated a large number of studies with only a few from Low and Middle Income Countries (LAMIC). Most of the studies were conducted through web-based surveys and some through faceto-face interviews during clinic consultations. Results showed a significant increase in anxiety and depression during the COVID-19 pandemic, with the prevalence of anxiety and depression during pregnancy being 69.4% 13 and 39.2% 14 and that in the postpartum being 35.8% 15 and 14.8% 16 .

A recent meta-analysis done by Fan et al 17 on psychological effects of COVID-19 on pregnant women, which included 19 studies with 15875 participants showed a 42% prevalence of anxiety and 25% prevalence of depression. Another metanalysis done on both pregnant and postpartum women which included 20569 participants from 23 studies showed high rates of anxiety and depression (37 % and 31% during pregnancy. The postpartum prevalence of depression was 22% 18 .

In addition to the above, obstetricians in an online survey from India reported that fears related to hospital visits for antenatal check-ups and ultrasound scans, protecting themselves from infection, social media messages, infant health after delivery, and breastfeeding were the most frequent concerns reported to them by women and their families 19 While depression and anxiety were a problem in pregnant and postpartum women during the pandemic, not much is known about the mental health and associated challenges specifically faced by women who have been diagnosed positive for COVID 19 infection especially around the time of childbirth. Only two studies are available on women with COVID Positive status 20, 21 . These studies were done using face-to-face interviews and the PHQ-9 and GAD-7 were used to assess anxiety and depression. The sample sizes in both studies were quite small (28 women and 11 women). One study showed no difference in anxiety between COVID Positive and non-COVIDpositive pregnant women and the study on 11 COVID Positive pregnant women showed lower levels of anxiety and depression at the tail end of a pandemic wave.

Our study aimed a) to find the prevalence of depression and anxiety among pregnant women admitted for labor who tested positive for COVID 19 infection and b) To study the association of various sociodemographic, social support, obstetric factors as well as that of COVID 19 related worries to depression and anxiety.

The study was conducted at the obstetrics inpatient setting in a public hospital in New Delhi which had a separate designated COVID-19 block.

A separate dedicated COVID 19 block was set up in the super-specialty block of the hospital in May 2020. It had facilities for asymptomatic and mildly symptomatic Covid 19 positive pregnant women including a dedicated negative pressure operation theatre. Women were housed in a 30 bedded ward with 5 cubicles. Government policies were followed and COVID-19 positive pregnant women who were asymptomatic or mildly symptomatic were admitted for isolation. Pregnant women were transferred to the COVID ward in an ambulance accompanied by a hospital worker. They could not meet their families physically for 10 days but could communicate with them through the landline phone at the nurses' workstation and their mobile phones. Following delivery, babies were roomed in with them and they were encouraged to use hand hygiene, sanitizers, and wear masks all the time especially while handling and feeding babies.

There was a separate delivery area within the same ward and all deliveries were conducted here. On a few occasions, the clinical condition of some patients deteriorated in the ward and they were shifted to the Intensive Care Unit.

Pregnant and postpartum women >18 years of age, who were admitted to the COVID 19 maternity ward for delivery were included for this study. None of them had any past or family history of psychiatric illness. Women with any severe mental illness or a severe medical illness were excluded. Of the 274 women admitted between 1 st May 2020 and 31 st December 2020, 243 were recruited following written informed consent. The women were interviewed over the telephone during admission in the COVID ward and again interviewed in person during the post-natal follow-up after 6 weeks by the investigator. Each interview was conducted over 30 to 40 minutes. All assessments were conducted within the first week of diagnosis of COVID 19 infection. Written informed consent was taken when patients were admitted and were taken from all participants before being interviewed in person. The study was approved by the institutional ethics committee of Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospital. Of the 243 women, 156 were diagnosed to be COVID-19 positive before delivery and 86 got their results after delivery. Anxiety and depression were assessed for 243 women when they were admitted and for 187 at their first follow-up, usually 6-8 weeks after delivery.

Sociodemographic details included age, religion, education, occupation, marital status, socioeconomic status, place of stay (rural or urban), family type (nuclear, joint, or extended). Obstetric details included parity, antenatal booking status, mode of delivery, pain in stitch line of cesarean section if postpartum, complications in the current pregnancy, previous pregnancy complications, previous history of psychiatric illness, and COVID-19 status of the baby. Details of puerperium and infant care noted were whether the infant was breastfed within an hour, whether mother was bathing the baby, sanitization of hands before infant feeding sessions, assistance received for feeding the baby during isolation, frequency of feeding the baby in 24 hours, care of the baby while visiting the washroom during isolation, being attended by the healthcare worker when called, difficulty in sleeping, how tiring it was to take care of self and the baby all by her own and the stigma after being informed about COVID positive status. Depression was assessed using the Patient Health Questionnaire 9(PHQ 9) an instrument used for screening, diagnosing, and measuring the severity of depression including perinatal depression. The PHQ 9 has been used in several studies in India and the Hindi version was used for this study 22 Scores of 1-4,5-9,10-19,20-27 represent minimal, mild, moderate, and severe depression respectively 23 . Anxiety was measured using the Hindi version of the Generalized Anxiety Disorder (GAD-7): GAD-7, which is a tool for screening and assessing the severity of anxiety. Scores of 0-4,5-9,10-14,15-21 are taken as the cut-off points for minimal, mild, moderate, and severe anxiety, respectively 24 . All postpartum women were asked a list of COVID19 related concerns using the COVID anxiety scale constructed for use among women in the perinatal period. It consisted of a set of 20 questions on a Likert scale of 0 to 3, that included several aspects related to worries about self and about the infant in the context of COVID 19 infection (Table 1) . These questions were based on items from the perinatal anxiety screening scale 25 , a questionnaire on attitude and behaviour related to COVID 19 26 , Coronavirus anxiety scale 27 , and expert advice from perinatal mental health professionals and obstetricians.

The normally distributed variables are expressed as mean ± standard deviation and continuous variables with skewed distribution as median (interquartile range). Categorical data presented as proportions categorical variables were compared using the Chi-square test/Fischer's exact test. All tests are two-sided with a significance level of 5%. Data were analyzed using SPSS software Version 24

Rates of depression and anxiety were calculated and univariate analysis was done to identify factors associated with moderate and severe anxiety and depression, using various sociodemographic and obstetric variables, the total COVID Anxiety Scale scores, social support score.

The mean age of the subjects was 26.86±4.31 years. While 153 women had primary school education or less, 90 women had education above high school. Majority of the women were married, from an urban background and 187 were from a lower socioeconomic status. Most women (162/243) women were living in a nuclear family, and 80 in a joint or extended family. Of the 243 women, 86 were primigravida and 157 women were multigravida and 159 were unbooked pregnancies. Among the women admitted 186 women were diagnosed to have COVID-19 positive just before delivery when they got tested as part of hospital protocol and 86 women delivered by the time they received results of COVID-19 positive status. The mode of delivery in 132 women was a normal vaginal delivery and 109 women had lower segment caesarean section (LSCS).

Pregnancy complications including eclampsia/preeclampsia, medical illness( Gestational diabetes, gestational hypertension, thyroid dysfunction, cardiac illness, renal complications), anhydramnios/ polyhydramnios/oligohydramnios,severe anemia,thrombocytopenia, infections(Hepatitis B and C Virus) , Rh Negative pregnancy, fetal related complications (Intrauterine growth retardation/shared circulation in twins) were seen in 92/243(37.86%) of women. Majority of the women(227/243) reported having breastfed their baby within one hour of delivery. Only 10 of the 232 infants tested were found to be positive for COVID I9 infection.

Most women handled (194/243) bathing of the infant on their own, with only 37 women requiring help from the staff and most women did not require any assistance in feeding the infant. Over 24 hours, 5 women reported having breastfed less than 6 times, while 226 women had fed their infant more than 6 times. Most women ( 184/243 reported difficulties in sleep). As the women did not have any birth companions in the COVID facility when patients, majority reported that other mothers in the ward helped them in looking after the infants. Women were satisfied with the health care workers and 205 women reported health care workers were always available on call for help.

Of the 243 women assessed using the PHQ 9, within 7 days of being diagnosed with COVID 19 infection, 45(18.51%) had minimal depression,168(69.13%) mild depressive symptoms, and 29(11.3%) had moderate. One woman had a severe depressive disorder. At the 6 weeks follow up, of 187 women who were assessed at, 31(16.57%) had minimal depression,131(70.05%) mild depression and 25 (13.36%) had moderate depression. Of the 243 women assessed using the GAD-7 at the time of delivery, 109(44.85%) had minimal anxiety,121(49.79%) had mild anxiety and 13 had moderate anxiety symptoms based on standard cut-offs. At 6 weeks follow-up, of the 185 assessed, 140(75.67%) had minimal anxiety, 44(23.78%) mild anxiety, and one woman (0.54%) had moderate anxiety.

The list of COVID 19 related worries and concerns is depicted in Table 1 and indicates fairly high levels of concerns related to the following -support during the postpartum period, child care support, stigma of having COVID 19 infection, poor access to health facilities for self and infant in the postpartum and health of other family members. Interestingly breast feeding was not a concern which is also indicated by the high rates of women who started breast feeding while still in hospital.

Univariate analysis using various sociodemographic and obstetric variables however did not reveal any factors that were significantly associated with moderate anxiety or depressive disorder.

Our study aimed at assessing the prevalence of anxiety and depression in women who were diagnosed with COVID-19 just before their delivery. There are significant challenges that pregnant and postpartum women face, especially as the pandemic has created uncertainties and new challenges that may make vulnerable women in the perinatal period more prone to psychological impacts such as anxiety and depression 1 . Studies done during COVID-19 have shown that pregnant women had fears of transmitting COVID-19 infection to the fetus and this in turn related to increased anxiety. A multinational study also revealed an increased prevalence of anxiety and depression in both pregnant and breastfeeding women. Factors associated with psychological morbidity included chronic mental illness, smoking and having an unplanned pregnancy 7 . Moderate or severe maternal anxiety was associated with the fear of being unaccompanied at childbirth 28 . While majority of the available studies are among pregnant and postpartum women attending antenatal services during the time of the pandemic, there are only a handful of studies (albeit with small sample sizes) that have specifically looked at women who have been diagnosed as having COVID infection at the time of childbirth. Labour and childbirth are known to be stressful times for mothers. With hospital policies not allowing a companion and the fears related to breastfeeding if mothers have COVID infection, this period can lead to even more psychological distress.

Our study has tried to address this lacuna in available literature and found the prevalence of depressive and anxiety symptoms in women to be quite high within a week of childbirth after having been diagnosed with COVID 19 infection and six weeks thereafter. Nearly 80.4% of women had mild or moderate depressive disorder and 61% had mild to moderate anxiety disorder. Rates of depression were slightly higher than baseline among women who came for follow up at 6 weeks (83 % versus 80% ) even though anxiety rates had reduced. Various practices adopted in course of the pandemic to mitigate these effects included frequent interaction between the patients and healthcare workers during ward rounds as well as on the telephone provided at the work station, telephonic conversations with family, facilitation of delivery of a few necessary things brought from home by family members and also psychiatry consultation in case of moderate and severe depression and anxiety. Previous studies from India and other LAMIC have shown rates of anxiety to be 23% 29 and depression 9.18% to 65.0% 30 in pregnancy and 22% 31 in the postpartum. During the COVID 19 pandemic, studies from LAMIC have shown GAD based rates for moderate depressive disorder to be 32.2% 32 and PHQ 9 rates of moderate depressive disorder to be 31% 33 .

The high levels of concerns and worries specifically related to COVID 19 infection, stigma and pandemic restrictions such as lockdowns are probably related to the high rates of anxiety and depression in out subjects. However, many of the previously identified factors associated with anxiety and depression in the perinatal period such as younger age, lower education, low socio economic status and poor social support did not show any association with moderate depressive or anxiety disorders in our sample 34-36 , 37 .

The worries and concerns in Table 1 indicate that stigma, poor access to infant health services and fear of poor support in the postpartum were high and possibly contributed to the high rates of anxiety and depression.

The strengths of the study include a fairly large sample size, systematic assessments using standard scales and having a follow up assessment in the postpartum. More importantly this is one of the few studies that has been done at the time of childbirth among a large sample of women diagnosed with COVID 19 infection. The assessments being done over phone when the women were admitted and not face to face as well as a postpartum follow up drop out rate of 58/243(23.86%) are some limitations.

Conclusions:There needs to be increased screening for common mental illnesses with timely identification of associated risk factors.Given the high rates of psychological distress, there is a strong need for liaison between obstetricians and mental health professionals. Obstetricians can address and reassure pregnant women regarding concerns about contracting the infection, worries about possible effects of COVID-19 on the fetus and newborn and concerns about future consultations. In case the worries are out of proportion and necessitate intervention by mental health professional's referral services should be made available. If such mental health concerns are addressed early, it prevents the long-term consequences on maternal mental health and also maternal-infant relationship. Hence identifying and addressing the mental health concerns will help to provide the optimum perinatal care during the pandemic.

There is a paucity of literature on pandemic effects on perinatal women who acquired COVID infection during childbirth. Further systematic and long-term studies are required to identify and address the mental health concerns during the perinatal period, especially since the pandemic has added additional stress.

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