key: cord-0853019-djitemau
authors: Zanardo, Vincenzo; Manghina, Valeria; Giliberti, Lara; Vettore, Michela; Severino, Lorenzo; Straface, Gianluca
title: Psychological impact of COVID‐19 quarantine measures in northeastern Italy on mothers in the immediate postpartum period
date: 2020-06-16
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13249
sha: c9c5621a6a5af64b67fefe8362488d96f205e1f8
doc_id: 853019
cord_uid: djitemau

OBJECTIVE: To explore whether quarantine measures and hospital containment policies among women giving birth in a COVID‐19 “hotspot” area in northeastern Italy enhanced psycho‐emotional distress in the immediate postpartum period. METHODS: We designed a non‐concurrent case–control study of mothers who gave birth during a COVID‐19 quarantine period between March 8 and May 3, 2020 (COVID‐19 study group), with an antecedent group of matched postpartum women (control group) who delivered in the same period in 2019. Participants completed the Edinburgh Postnatal Depression Scale (EPDS) on the second day postpartum. RESULTS: The COVID‐19 study group (n=91) had significantly higher mean EPDS scores compared with the control group (n=101) (8.5 ± 4.6 vs 6.34 ± 4.1; P<0.001). Furthermore, 28.6% of women in the COVID‐19 group had a global EPDS score above 12. Analysis of three EPDS subscales revealed significantly higher scores among the COVID‐19 group compared with the control group for anhedonia (0.60 ± 0.61 vs 0.19 ± 0.36; P<0.001) and depression (0.58 ± 0.54 vs 0.35 ± 0.45; P=0.001). CONCLUSIONS: Concerns about risk of exposure to COVID‐19, combined with quarantine measures adopted during the COVID‐19 pandemic, adversely affected the thoughts and emotions of new mothers, worsening depressive symptoms.

In February 2020, northern Italy became the epicenter for coronavirus disease 2019 in Europe, with many exportations to other countries and widespread community transmission, particularly within the region. 1 Hence, on that date, quarantine was extended nationwide until April 13 to limit viral transmission. 2, 3 Following the Decree of The Council of Ministers on April 10, 2020, all measures to counter the spread of coronavirus infection were extended until May 3. After this date, phase two began, with eased lockdown measures implemented to "coexist" with the coronavirus.

The study was designed as a non-concurrent case-control study on psycho-emotional distress in the immediate postpartum period in women who gave birth at Policlinico Abano Terme (COVID-19 study group) and an antecedent group of matched postpartum women (control group). Data collection was approved by the Institutional Review Board (IRB) of Policlinico Abano Terme. Ethical approval was also obtained from the IRB. All participants were given an information sheet and were only included in the study if they had signed the consent form.

Women aged over 18 years who could read and understand Italian, who had delivered a singleton, healthy neonate at term at Policlinico Abano Terme between March 8 (start of nationwide quarantine) and

May 3 (quarantine measures eased), 2020 were consecutively asked to participate. A control group of women was also recruited, comprising women aged over 18 years (able to read and understand Italian) who lived in the same geographic area and had delivered at the hospital in the same time period as the study group but in the previous year (2019). This was possible because mothers provided written permission for us to access their obstetric records, which included basic personal data, education, medical history, and pre-discharge EPDS screening results. A total of 11 women were excluded from the study group: 5 whose length of hospital stay was prolonged; 2 who underwent general anesthesia; 1 who underwent psychological treatment; 1 who required hospitalization for COVID-19; and 2 whose infants had jaundice. Four women were excluded from the control group: 3 whose length of hospital stay was prolonged and 1 whose infant had jaundice. Among eligible mothers, seven subsequently declined to participate (6 in the study group and 1 in the control group). In addition, five women in the study group were excluded owing to incomplete data. Thus, data from 91 women in the study group and 101 in the control group were analyzed. SPSS version 19 (IBM, Armonk, NY, USA) was used for analysis.

Data are expressed as mean ± SD or number (percentage). EPDS global score and values for the three subscales of anhedonia, anxiety, and depression were determined for the study and control groups.

Continuous variables were analyzed by independent sample t test, while the Fisher exact test was used to analyze qualitative variables.

P<0.05 was considered statistically significant.

The sociodemographic characteristics and clinical features of 91 study group mothers and 101 control group mothers are shown in Table 1 .

There were no significant differences between the groups for all variables except neonatal birth weight, which was significantly lower in the babies born during the COVID-19 pandemic compared with the previous year (3354.51 ± 374.2 vs 3478.60 ± 409.8 g; P=0.031).

Pre-discharge EPDS, anhedonia, anxiety, and depression subscale scores collected on the second day postpartum for the COVID-19 study group and control group are shown in Table 2 . Mean EPDS scores were significantly higher in the COVID-19 study group compared with the control group (8.5 ± 4.6 vs 6.34 ± 4.1; P<0.001). The percentage of high-risk women, those with a global EPDS score above 12, was also significantly higher in the COVID-19 group compared with the control group (28.6% vs 11.9%; P=0.006).

EPDS subscale analysis showed that mean scores for anhedonia, anxiety, and depression were all higher in the COVID-19 study group compared with the control group, although the differences were only significant for anhedonia (0.60 ± 0.61 vs 0.19 ± 0.36; P<0.001) and depression (0.58 ± 0.54 vs 0.35 ± 0.45; P=0.001).

The present study found that women giving birth during a period of COVID-19 quarantine measures adopted in a hotspot area in northeastern Italy between March 8 and May 3, 2020, presented higher EPDS scores compared with a control group of mothers who gave birth during the same period the previous year. Furthermore, almost 30% of mothers in the COVID-19 group had a global EPDS score above 12, which may lead to a higher risk of postnatal depression. Analysis of three EPDS subscales revealed significantly higher scores for anhedonia and depression in the COVID-19 study group, highlighting the additional beneficial tools within the EPDS that may allow better understanding of the spectrum of various negative psychological issues that the COVID-19 pandemic might arouse among pregnant women and new mothers.

The present findings suggest that postpartum psychological responses during the COVID-19 pandemic may be mediated by EPDS symptoms that are severe enough to predict a higher risk of postnatal depression. Therefore, pregnant women giving birth during the COVID-19 pandemic represent a high-risk, vulnerable population that needs to be carefully followed to minimize postpartum mental dysfunction, as previous studies have reported following natural disasters. 16 Medical and mental healthcare interventions should be carried out immediately to prevent deterioration of maternal psychological health, which is made more severe by social containment than reported for previous natural disasters. 11 These data may have some clinical relevance. Pregnancy can be a stressful time for many expectant mothers 17 ; however, the COVID-19 crisis is adding a new layer of worry about how the pandemic will Furthermore, an intrinsically observational study such as this cannot guarantee that the observed relationships represent causal factors.

Finally, the study sample is limited, geographically specific, and not generalizable. However, this should not invalidate the results because the general demographic variables were similar among the groups.

Literature on this subject is limited; therefore, the present study makes an important contribution to understanding the impact of a natural infectious calamity on pregnant women.

In conclusion, the results of our study indicate that quarantine and hospital containment measures adopted in a COVID-19 hotspot area in northeastern Italy had a strong psycho-emotional impact on women giving birth during this period, as indicated by increased EPDS scores and anhedonia and depression subscale scores in the immediate postpartum period. Concerns about risk of exposure to COVID-19, combined with quarantine measures, can worsen depressive symptoms and adversely affect the thoughts, emotions, and functioning of new mothers.

VZ carried out the study. GS and LS participated in study design. VM and LG participated in study design and coordination. MV helped draft the manuscript. All authors read and approved the final manuscript.

The authors have no conflicts of interest.

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study

Only strict quarantine measures can curb the coronavirus disease (COVID-19) outbreak in Italy

Suppression of COVID-19 outbreak in the municipality of

Women's health-related vulnerabilities in natural disasters: A systematic review protocol

Pathophysiological Mechanisms Implicated in Postpartum Depression

The psychological impact of quarantine and how to reduce it: Rapid review of the evidence

SARS control and psychological effects of quarantine

Coronavirus disease 2019 (COVID-19) pandemic and pregnancy

Chronology of main steps and legal acts taken by the Italian Government for the containment of the COVID-19 epidemiological emergency

Analysis of the susceptibility to COVID-19 in pregnancy and recommendations on potential drug screening

Mental Health Outcomes of Quarantine and Isolation for Infection Prevention: A Systematic Umbrella Review of the Global Evidence

Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale

Subscales measuring symptoms of non-specific depression, anhedonia, and anxiety in the Edinburgh Postnatal Depression Scale

Using the Edinburgh Postnatal Depression Scale to screen for anxiety disorders

Subconstructs of the Edinburgh Postpartum Depression Scale in a Multi-Ethnic Inner-City Population in the U.S. Arch Womens Ment Health

When is exposure to natural disaster traumatic? Comparison of trauma questionnaire and disaster exposure inventory

Effects of prenatal stress on pregnancy and human development: mechanisms and pathways

Identifying the women at risk of antenatal anxiety and depression: A systematic review

Biological and psychosocial predictors of postpartum depression: Systematic review and call for integration

World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 -2

Postpartum depression risk factors: A narrative review

Identification and management of peripartum depression

Mental health and a novel coronavirus (2019-nCoV) in China