Anxiety, depression, worry, and stress-related perceptions among antenatal women during the COVID-19 pandemic: Single group repeated measures design.

Background: Coronavirus disease 2019 (COVID-19) has rapidly spread across the globe, which has affected the health of all populations including antenatal women. Aims: The aim of the study was to evaluate the levels of anxiety, depression, stress, and worry in antenatal women during COVID-19 compared with the pre-COVID-19 levels and to evaluate the associations between the sociodemographic factors of antenatal women and Hospital Anxiety Depression Scale (HADS)-D, HADS-A, Generalized Anxiety Disorder (GAD)-7, Perceived Stress Scale (PSS), and Brief Measure of Worry Severity (BMWS) scores. Materials and
Methods: This single group repeated measures design was conducted on 101 antenatal women who were referred to outpatient antenatal clinics from January 2020 (pre-COVID-19) to April 2020 (during the COVID-19 pandemic). Data were collected using four questionnaires including the HADS, GAD-7 scale, PSS, and BMWS.
Results: Antenatal women (n = 101, Mage = 32.73 years, standard deviation = 5.67) during COVID-19 demonstrated significantly increased (P < 0.001) levels of anxiety, depression, stress, and worry compared with pre-COVID-19 levels. Multiple regression analysis indicated that panic disorder was significantly associated with HADS, PSS, and BMWS scores; pregnancy complications were significantly associated with HADS scores; associated health problems were significantly associated with PSS and BMWS scores; and current anxiety, depression, stress, and worry were significantly associated with HADS, GAD-7, and BMWS scores in antenatal women during COVID-19.
Conclusion: Increased attention should be paid to the psychological health of antenatal women during this COVID-19 pandemic. Proper management of this current catastrophe is likely to result in global changes in social experiences, and interventions are necessary to address associated changes in mental health, especially among antenatal women. Copyright:

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has briskly extent across the world, which has exaggerated the health of all populations, including pregnant women.[1] Antenatal women exist in a state of unique immune tolerance and are particularly vulnerable to the virus, and many confirmed cases of infection in pregnant women have been documented.[2] COVID-19 is a major public health issue that also represents an obstetrical management concern when determining the optimal treatments for pregnant women.[3] Although medical associations worldwide have established clinical guidelines for the management of pregnant women during this pandemic, suggestions associated with the management of mental health have been constrained by the absence of experimental data.[4] Antenatal research associated with COVID-19 has predominantly concentrated on the maternal and neonatal consequences of COVID-19 infections during pregnancy.[5] Therefore, in the present study, we aimed to examine the impacts of the COVID-19 pandemic on the psychological well-being of pregnant women.

Women are extremely responsive to stress during pregnancy,[6] and nearly 25% of them report emotional distress during the antenatal period.[7] Anxiety, depression, and stress-related disorders have frequently been reported in antenatal women because pregnancy involves substantial changes, both physically and psychologically.[8] These adjustments to the body have been associated with an extensive rise in mental health symptoms,[9] leading to various medical and obstetric complications during pregnancy.[10]

Pregnancy is a period during which women are susceptible to stress, which can increase anxiety and depression.[11] Studies have suggested that the incidence of stress during pregnancy varies from 5.5% to 78%.[1112] Enhanced levels of stress can increase gestational hypertension, miscarriage, preeclampsia for antenatal women, and vision and hearing impairments, developmental delays, preterm birth, and low-birth-weight for infants.[13]

The second most common complication that affects women during pregnancy is depression.[14] Depression is a mood disorder that triggers a constant feeling of unhappiness and a loss of interest that can lead to a variety of emotional and physical problems,[15] which can decrease an individual’s ability to perform at both work and home.[16] Up to 70% of females have reported indications of depression during pregnancy, and 10%–16% of pregnant women present the symptoms of major depressive disorder[17] including a decreased maternal awareness toward the baby.[18]

Worry is also a common factor that affects the quality of life in women during pregnancy.[19] Consequently, worry is strongly correlated with fear, and moderate-to-high levels of worry have been reported in pregnant women.[20] The primary causes for worry in pregnant women include (1) Health during pregnancy, especially during pandemic times; (2) the health of the baby; (3) family and childcare; (4) accommodations and financial constraints; (5) newborn health, care, and breastfeeding.[21]

Generally, in research settings, antenatal anxiety, depression, stress, and worry have been evaluated using a wide range of self-report scales, which have been validated and are reliable.[22] The Hospital Anxiety and Depression Scale-Depression (HADS-D), HADS-Anxiety (HADS-A),[23] Generalized Anxiety Disorder-7 (GAD-7),[24] Perceived Stress Scale (PSS),[25] and Brief Measure of Worry Severity (BMWS),[26] are commonly used in clinical settings to determine the anxiety, stress, and worry levels in antenatal women. The current article reviews the significant effects of COVID-19 on maternal mental health using these questionnaires.

The objectives of the present study were as follows (1) To evaluate the levels of anxiety, depression, stress, and worry in antenatal women during COVID-19 compared with the pre-COVID-19 levels; (2) to evaluate the associations between the sociodemographic factors of antenatal women and HADS-D, HADS-A, GAD-7, PSS, and BMWS scores.

MATERIALS AND METHODS

Participants

In this single group repeated measures design, data were collected from antenatal women (n = 101) enrolled at the King Khalid University out-patient clinic in Abha, Saudi Arabia. Before performing the assessment, the examiner explained the process and the purpose of the study to all participants. During the pre-COVID-19 period (January 14, 2020) as a part of our study, antenatal women were invited to participate in the study. All subjects included in this study signed informed written consent. During the COVID-19 pandemic, the repurpose of the study was explained to the same participants. They were contacted by phone, secondary reconsent procedures were obtained, and asked to participate in the study, which occurred when the pandemic was properly underway, from March 27 to June 24, 2020.

The inclusion criteria were: (1) Antenatal women aged between 20 and 45 years (2) who were willing to participate in the study. The exclusion criteria were: (1) The inability to understand and respond to the questionnaire and (2) a recent, positive COVID-19 result.

The Ethical Committee of King Khalid University approved the present study protocol (ECM#2020-0909).

Procedures

Demographic data (age and gender), and anthropometric factors, including height (m), weight (kg), and body mass index (kg/m2), were evaluated for all participants using standard procedures. Data regarding employment history, duration of infertility, method of pregnancy, parity, medication use, any recent hospitalization, any chronic health problems, family history of psychiatric illness, history of pregnancy complications, and any history of panic disorders were also collected for the study. After completing this procedure during the pre-COVID-19 assessment, the researchers explained each questionnaire to all subjects in detail and asked them to fill out the forms. During the COVID-19 pandemic, we used authorized internet platforms, including E-mail, WhatsApp, and Facebook, to ask participants to respond to the same questionnaires in electronic format, instructed to mail the filled questionnaires to the research team, which were sent to them.

Measures

Hospital anxiety and depression scale

HADS is a commonly popular screening tool that was established to evaluate anxiety and depression. HADS is a 14-item scale comprised two subscales, the HADS-A for anxiety and the HADS-D for depression. Both subscales consist of seven items, and each item is scored between 0 and 3. A score of 0–7 was considered normal, 8–10 was considered borderline, and 11–21 was considered abnormal for each subscale.[23]

Generalized anxiety disorder-7

The scale consists of 7 items, asking participants how frequently during the last 2 weeks they were concerned about each symptom. The response possibilities were “not at all,” “several days,” “more than half the days,” and “nearly every day,” which were recorded as 0, 1, 2, and 3, respectively. Scores of 5, 10, and 15 corresponding to cut-off points for mild, moderate, and severe anxiety, respectively.

Perceived stress scale

The PSS consists of 10 questions regarding the levels of feelings and thoughts encountered during the last month and how often they experienced these feelings. The scores were recorded as 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often. Moreover, all questions were of a common nature and generally free of content particular to any subpopulation group.[25]

Brief measure of worry severity

The BMWS was established as a unidimensional assessment scale to measure the impacts of varying degrees of worry.[26] Subjects were asked to rate their general or usual level of worrying, with four response options: 0 = Not true at all, 1 = Somewhat true, 2 = Moderately true, and 3 = Definitely true. The answers for all questions are summed to obtain a total score, with higher aggregate scores demonstrating higher levels of worry in antenatal women.

Data analysis

SPSS software (version 24.0 for Windows; SPSS, Inc., Chicago, Illinois, USA) was used to conduct statistical analyses. Descriptive statistics were used to characterize the socioeconomic demographic characteristics and obstetric characteristics of the sample. To meet our first aim, we performed an independent Student’s t-test to evaluate differences in the HADS-D, HADS-A, GAD7, PSS, and BMWS scores between before and during COVID-19. To meet our second aim, we then executed linear regression analysis with the personal characteristics of antenatal women as predictors and the scores of all five scales used in this study as the dependent factors. The co-variables included in our linear regression model were based on reviewing previous literature and given their significance and substantial influence on anxiety, depression, worry, and stress levels among antenatal women. The significance level was at P < 0.05 for all analyses.

RESULTS

The pre-COVID-19 and COVID-19 cohorts consisted of the same sample, which was comprised 117 pregnant women, varying from 20 to 45 years old (mean [M] = 32.73 years, standard deviation = 5.67). Out of 117 participants, sixteen subjects were not included in the final analysis as eleven participants did not respond, and five participants partially filled the questionnaires. The clinical and demographic characteristics of all participants are represented in Table 1. Among the participants, the proportion of women who reported being unemployed during COVID-19 increased from 23.7% to 43.6%. Approximately 28% of women were expecting their first child, and >63% of women suffered from panic disorder during COVID-19 when compared to pre-COVID-19 period. The majority of antenatal women (75.2%) experienced two or more pregnancy complications during the COVID-19 period, whereas only 24.8% experienced no complications.

Table 1

Clinical and sociodemographic characteristics of antenatal women (n=101)

Variable	Mean±SD
	Pre-COVID-19	During COVID-19
Age (years)	32.73±5.67	32.73±5.67
Height (m)	1.65±0.06	1.65±0.06
Weight (kg)	69.31±8.42	72.19±8.38
BMI	25.46±3.90	26.44±2.58
Employment frequency, n (%)
Yes	77 (76.2)	57 (56.4)*
No	24 (23.7)	44 (43.6)*
Duration of infertility (years) frequency, n (%)
0	8 (7.9)	8 (7.9)
1	18 (17.8)	18 (17.8)
2	5 (5.0)	5 (5.0)
3	12 (11.9)	12 (11.9)
4	9 (8.9)	9 (8.9)
5	12 (11.9)	12 (11.9)
6	12 (11.9)	12 (11.9)
7	6 (5.9)	6 (5.9)
8	6 (5.9)	6 (5.9)
9	6 (5.9)	6 (5.9)
10	7 (6.9)	7 (6.9)
Method of pregnancy frequency, n (%)
Normal	55 (54.5)	55 (54.5)
IVF	19 (18.8)	19 (18.8)
IUI	27 (26.7)	27 (26.7)
Parity frequency, n (%)
Primiparous	28 (27.7)	28 (27.7)
Multiparous	72 (72.3)	72 (72.3)
Any use of medication frequency, n (%)
Yes	63 (62.3)	88 (87.1)*
No	38 (37.6)	13 (12.9)*
Any recent hospitalization frequency, n (%)
Yes	26 (25.7)	68 (67.3)*
No	75 (74.2)	33 (32.7)*
Exercise (min/day) frequency, n (%)
0	35 (34.6)	83 (82.2)*
15-0	49 (48.5)	16 (15.8)*
31-45	17 (16.8)	2 (2.0)*
Any health problems frequency, n (%)
Yes	54 (53.4)	71 (70.3)*
No	47 (46.5)	30 (29.7)*
Any family history of psychiatric illness frequency, n (%)
Yes	53 (52.5)	53 (52.5)
No	48 (47.5)	48 (47.5)
Any pregnancy complications frequency, n (%)
Yes	58 (57.4)	76 (75.2)*
No	43 (42.5)	25 (24.8)*
Any panic disorder frequency, n (%)
Yes	24 (23.7)	63 (62.4)*
No	77 (76.2)	38 (37.6)*
Currently any anxiety, depression, stress, and worry? frequency, n (%)
Yes	41 (40.5)	89 (88.1)*
No	60 (59.4)	12 (11.9)*

Significant difference: P<0.05 level. COVID-19 – Coronavirus disease 2019; BMI – Body mass index; SD – Standard deviation; IUI – Intrauterine insemination; IVF – In vitro fertilization

Table 2 shows HADS-D, HADS-A, GAD-7, PSS, and BMWS scores both pre-COVID-19 and during COVID-19, revealing significant differences (P < 0.001) in all outcomes. The levels of severe depression, anxiety, stress, and worry increased during COVID-19 compared with the pre-COVID-19 levels.

Table 2

Analysis of Hospital Anxiety and Depression Scale (depression), Hospital Anxiety and Depression Scale (anxiety), generalized anxiety disorder-7, Perceived Stress Scale, and Brief Measure Of Worry Scale scores during precoronavirus disease 2019 and during coronavirus disease 2019 in antenatal women

Scale	Mean±SD		95% CI (lower bound-upper bound)	P
	Pre-COVID-19	During COVID-19
HADS-D	3.96±1.74	8.55±4.71	−5.62-−3.56	<0.001*
HADS-A	5.36±2.77	11.05±4.07	−6.59-−4.79	<0.001*
GAD-7	5.24±2.80	11.01±4.28	−6.74-−4.79	<0.001*
PSS	16.57±5.45	25.41±7.28	−9.97-−7.70	<0.001*
BMWS	14.09±4.22	19.98±3.88	−6.74-−5.01	<0.001*

*Significant difference: P<0.05. HADS-D – Hospital Anxiety and Depression Scale (depression); HADS-A – Hospital Anxiety and Depression Scale (anxiety); GAD-7 – Generalized anxiety disorder-7; PSS – Perceived Stress Scale; BMWS – Brief Measure Of Worry Scale; COVID-19 - Coronavirus disease 2019; SD – Standard deviation; CI – Confidence interval

We then performed multiple linear regression analyses to analyze the association between the socioeconomic demographic characteristics and the HADS-D, HADS-A, GAD-7, PSS, and BMWS scores for the period’s pre-COVID-19 [Table 3] and during COVID-19 [Table 4]. For the pre-COVID-19 period, the method of pregnancy and duration of infertility were identified as the best predictors of HADS-A and GAD-7, whereas the method of pregnancy and recent hospitalization were the best predictors of the PSS score (P < 0.001). We also observed that 22% of the variations in the HADS-A scores (Adjusted R2 = 0.226), 21% of the variations in GAD-7 scores (Adjusted R2 = 0.214), 52% of the variations in PSS scores (Adjusted R2 = 0.524), and only 14% of the variations in the BMWS scores (Adjusted R2 = 0.142) could be accounted for by the predictors used in the present study [Table 3]. No significant impacts of predictors were identified for the HADS-D during the pre-COVID-19 period in this study.

Table 3

Multiple regression analysis assessing the correlation between sociodemographic characteristics with Hospital Anxiety and Depression Scale (depression), Hospital Anxiety and Depression Scale (anxiety), generalized anxiety disorder-7, Perceived Stress Scale, and brief measure of worry scale during precoronavirus disease 2019

Scale	Predictors	Adjusted R2	B	SE	Β	P	95% CI (lower bound-upper bound)
HADS-D	Method of pregnancy	0.008	0.044	0.241	0.022	0.855	−0.434-0.523
	Duration of infertility		−0.014	0.070	−0.025	0.836	−0.153-0.124
	Parity		0.177	0.450	0.046	0.695	−0.717-1.07
	Use of medication		−1.09	0.740	−0.212	0.141	−2.56-0.371
	Recent hospitalization		−0.487	0.496	−0.132	0.330	−1.47-0.500
	Exercise		0.621	0.432	0.159	0.154	−0.237-1.47
	Associated health problems		0.475	0.543	0.125	0.384	−0.604-1.55
	Family history of psychiatric illness		0.824	0.469	0.237	0.082	−0.107-1.75
	Pregnancy complications		0.181	0.540	0.045	0.739	−0.893-1.25
	Any panic disorder		−0.269	0.437	−0.075	0.540	−1.13-0.600
	Current anxiety, depression, stress, and worry		0.283	0.699	0.053	0.687	−1.10-1.67
HADS-A	Method of pregnancy	0.226	1.02	0.359	0.317	0.005*	0.307-1.73
	Duration of infertility		−0.356	0.104	−0.388	0.001*	−0.562-−0.149
	Parity		0.991	0.671	0.161	0.143	−0.342-2.32
	Use of medication		−1.05	1.10	−0.128	0.340	−3.24-1.13
	Recent hospitalization		0.868	0.740	0.147	0.244	−0.602-2.33
	Exercise		−0.285	0.644	−0.046	0.659	−1.56-0.994
	Associated health problems		0.777	0.809	0.129	0.340	−0.831-2.38
	Family history of psychiatric illness		0.443	0.698	0.080	0.527	−0.944-1.831
	Pregnancy complications		0.647	0.805	0.101	0.424	−0.954-2.24
	Any panic disorder		−0.666	0.651	−0.117	0.309	−1.96-0.628
	Current anxiety, depression, stress, and worry		−1.64	1.04	−0.192	0.119	−3.71-0.429
GAD-7	Method of pregnancy	0.214	1.04	0.365	0.320	0.005*	0.314-1.76
	Duration of infertility		−0.342	0.106	−0.370	0.002*	−0.552-−0.132
	Parity		1.22	0.683	0.196	0.077	−0.133-2.57
	Use of medication		0.047	1.12	0.006	0.967	−2.18-2.27
	Recent hospitalization		0.436	0.753	0.073	0.564	−1.05-1.93
	Exercise		−0.168	0.655	−0.027	0.798	−1.47-1.13
	Associated health problems		0.377	0.823	0.062	0.648	−1.25-2.01
	Family history of Psychiatric illness		0.418	0.711	0.075	0.558	−0.994-1.83
	Pregnancy complications		0.430	0.820	0.067	0.602	−1.19-2.05
	Any panic disorder		−0.743	0.663	−0.129	0.265	−2.06-0.573
	Current anxiety, depression, stress, and worry		−1.68	1.06	−0.195	0.116	−3.79-0.423
PSS	Method of pregnancy	0.524	−2.98	0.554	−0.471	0.000*	−4.08-−1.88
	Duration of infertility		0.138	0.160	0.077	0.391	−0.180-0.457
	Parity		−1.55	1.03	−0.128	0.136	−3.61-0.500
	Use of medication		0.539	1.70	0.033	0.752	−2.84-3.91
	Recent hospitalization		−5.53	1.14	−0.478	0.000*	−7.80-−3.26
	Exercise		−0.951	0.993	−0.078	0.341	−2.92-1.02
	Associated health problems		−3.19	1.24	−0.268	0.012	−5.67-−0.709
	Family history of psychiatric illness		0.504	1.07	0.046	0.641	−1.63-2.64
	Pregnancy complications		−2.46	1.24	−0.196	0.051	−4.93-0.006
	Any panic disorder		0.819	1.00	0.073	0.417	−1.17-2.81
	Current anxiety, depression, stress, and worry		−2.29	1.60	−0.137	0.157	−5.49-0.898
BMWS	Method of pregnancy	0.142	−0.762	0.575	−0.155	0.189	−1.90-0.381
	Duration of infertility		0.137	0.166	0.098	0.412	−0.193-0.468
	Parity		0.778	1.07	0.083	0.471	−1.35-2.91
	Use of medication		−1.94	1.76	−0.155	0.274	−5.45-1.56
	Recent hospitalization		−0.243	1.18	−0.027	0.838	−2.59-2.11
	Exercise		−0.929	1.03	−0.099	0.370	−2.97-1.11
	Associated health problems		−2.11	1.29	−0.230	0.106	−4.69-0.458
	Family history of psychiatric illness		1.04	1.11	0.124	0.353	−1.17-3.26
	Pregnancy complications		1.21	1.29	0.125	0.350	−1.35-3.77
	Any panic disorder		0.270	1.04	0.031	0.796	−1.80-2.34
	Current anxiety, depression, stress, and worry		−1.72	1.67	−0.133	0.304	−5.04-1.59

*Significant difference: P<0.05. HADS-D – Hospital Anxiety and Depression Scale (depression); HADS-A – Hospital Anxiety and Depression Scale (anxiety); GAD-7 – Generalized anxiety disorder-7; PSS – Perceived Stress Scale; BMWS – Brief Measure Of Worry Scale; COVID-19 – Coronavirus disease 2019; SD – Standard error; CI – Confidence interval

Table 4

Multiple regression analysis assessing the correlation between sociodemographic characteristics with Hospital Anxiety and Depression Scale (depression), Hospital Anxiety and Depression Scale (anxiety), generalized anxiety disorder-7, Perceived Stress Scale, and Brief Measure Of Worry Scale during coronavirus disease 2019

Scale	Predictors	Adjusted R2	B	SE	β	P	95% CI (lower bound-upper bound)
HADS-D	Method of pregnancy	0.229	2.03	0.609	0.372	0.001*	0.827-3.24
	Duration of infertility		−0.337	0.176	−0.217	0.059	−0.688-0.013
	Parity		1.95	1.13	0.186	0.090	−0.309-4.21
	Use of medication		−1.25	1.87	−0.090	0.502	−4.97-2.45
	Recent hospitalization		0.462	1.25	0.046	0.714	−2.03-2.95
	Exercise		−0.266	1.09	−0.025	0.808	−2.43-1.90
	Associated health problems		1.66	1.37	0.162	0.229	−1.06-4.39
	Family history of psychiatric illness		0.091	1.18	0.010	0.939	−2.26-2.44
	Pregnancy complications		0.008	1.36	0.001	0.996	−2.70-2.72
	Any panic disorder		−2.29	1.10	−0.237	0.004*	−4.48-−0.097
	Current anxiety, depression, stress, and worry		−0.926	1.76	−0.064	0.602	−4.43-2.58
HADS-A	Method of pregnancy	0.392	0.097	0.467	0.020	0.837	−0.831-1.02
	Duration of infertility		0.066	0.135	0.049	0.625	−0.202-0.335
	Parity		−1.43	0.873	−0.159	0.103	−3.17-0.295
	Use of medication		−1.17	1.43	−0.097	0.414	−4.02-1.67
	Recent hospitalization		−0.622	0.962	−0.072	0.520	−2.53-1.29
	Exercise		−1.03	0.837	−0.113	0.221	−2.69-0.633
	Associated health problems		0.629	1.05	0.071	0.552	−1.46-2.72
	Family history of psychiatric illness		0.232	0.909	0.029	0.799	−1.57-2.03
	Pregnancy complications		−1.47	1.04	−0.157	0.002*	−3.55-0.606
	Any panic disorder		−2.53	0.847	−0.303	0.004*	−4.21-−0.852
	Current anxiety, depression, stress, and worry		−3.38	1.35	−0.271	0.000*	−6.08-−0.694
GAD-7	Method of pregnancy	0.310	0.977	0.523	0.196	0.001*	−0.063-2.017
	Duration of infertility		0.085	0.151	0.060	0.576	−0.216-0.386
	Parity		−1.914	0.978	−0.201	0.054	−3.857-0.030
	Use of medication		0.231	1.607	0.018	0.886	−2.962-3.424
	Recent hospitalization		0.416	1.079	0.046	0.701	−1.728-2.560
	Exercise		0.075	0.938	0.008	0.004	−1.790-1.939
	Associated health problems		0.273	1.180	0.029	0.818	−2.072-2.618
	Family history of psychiatric illness		−0.507	1.018	−0.059	0.620	−2.531-1.516
	Pregnancy complications		−0.206	1.174	−0.021	0.861	−2.540-2.127
	Any panic disorder		−0.118	0.950	−0.013	0.901	−2.005-1.768
	Current anxiety, depression, stress, and worry		−6.378	1.519	−0.484	0.000*	−9.397-−3.359
PSS	Method of pregnancy	0.559	−0.877	0.711	−0.104	0.220	−2.28-0.535
	Duration of infertility		0.349	0.206	0.145	0.093	−0.060-0.757
	Parity		−2.78	1.32	−0.172	0.039	−5.42-−0.146
	Use of medication		3.55	2.18	0.164	0.107	−0.785-7.88
	Recent hospitalization		−6.87	1.46	−0.445	0.000*	−9.78-−3.96
	Exercise		−1.32	1.27	−0.081	0.302	−3.85-1.21
	Associated health problems		−5.88	1.60	−0.371	0.000*	−9.06-−2.69
	Family history of psychiatric illness		−1.12	1.38	−0.077	0.420	−3.86-1.62
	Pregnancy complications		−1.36	1.59	−0.081	0.395	−4.53-1.80
	Any panic disorder		−1.27	1.29	−0.085	0.000*	−3.84-1.28
	Current anxiety, depression, stress, and worry		−1.97	2.06	−0.088	0.342	−6.07-2.13
BMWS	Method of pregnancy	0.425	−0.017	0.433	−0.004	0.968	−0.878-0.844
	Duration of infertility		0.155	0.125	0.121	0.219	−0.094-0.405
	Parity		−0.221	0.810	−0.026	0.786	−1.83-1.38
	Use of medication		0.180	1.33	0.016	0.893	−2.46-2.82
	Recent hospitalization		−1.24	0.893	−0.151	0.000*	−3.01-0.534
	Exercise		−0.735	0.777	−0.085	0.347	−2.27-0.809
	Associated health problems		−3.29	0.977	−0.390	0.000*	−5.24-−1.35
	Family history of psychiatric illness		−0.013	0.843	−0.002	0.988	−1.68-1.66
	Pregnancy complications		−0.011	0.973	−0.001	0.991	−1.94-1.92
	Any panic disorder		−0.202	0.786	−0.025	0.000*	−1.76-1.36
	Current anxiety, depression, stress, and worry		−2.31	1.25	−0.194	0.000*	−4.81-0.183

*Significant difference: P<0.05. HADS-D – Hospital Anxiety and Depression Scale (depression); HADS-A – Hospital Anxiety and Depression Scale (anxiety); GAD-7 – Generalized anxiety disorder-7; PSS – Perceived Stress Scale; BMWS – Brief Measure Of Worry Scale; COVID-19 – Coronavirus disease 2019; SD – Standard error; CI – Confidence interval

During the COVID-19 pandemic period, the method of pregnancy and panic disorder were the best predictors of the HADS-D score; pregnancy complications, panic disorder, and current anxiety, depression, stress, and worry factors were the best predictors of the HADS-A score; the method of pregnancy, associated health problems, and current anxiety, depression, stress, and worry factors were the best predictors for the GAD-7 score; recent hospitalization, associated health problems, and panic disorder were the best predictors of the PSS score; and recent hospitalization, associated health problems, panic disorder, and current anxiety, depression, stress, and worry factor were the best predictors of the BMWS score (P < 0.005).

We observed that 22% of the variation in the HADS-D score (Adjusted R2 = 0.229), 39% of the variation in the HADS-A score (Adjusted R2 = 0.392), 31% of the variation in the GAD-7 score (Adjusted R2 = 0.310), 55% of the variation in the PSS score (Adjusted R2 = 0.559), and more than 42% of the variation in the BMWS score (Adjusted R2 = 0.425) could be explained by the predictors used in the study [Table 4]. We also observed that the predictors significantly impacted the worry factor and panic disorder more strongly during COVID-19 than before COVID-19.

DISCUSSION

The present COVID-19 pandemic represents a major challenge worldwide, causing harmful effects on health. No population is safe from the effects of COVID-19, including antenatal women.[27] To the best of our knowledge, this study is the first to identify a substantial escalation in anxiety, depression, stress, and worry symptoms among antenatal women during COVID-19 compared with the levels in the pre-COVID-19 period. We measured the HADS-D, HADS-A, GAD-7, PSS, and BMWS scales in the same cohort both before and during the COVID-19 pandemic and observed clear variations.

This study revealed that during the pandemic, antenatal women reported a higher rate of medication use, recent hospitalizations, associated health problems, panic disorder, and current anxiety, depression, stress, and worry levels when compared with the pre-COVID-19 period. These results were consistent with those described in previous studies.[428]

According to the HADS-D scores, 10% of respondents reported borderline depression, and 36% of respondents reported abnormal depression. According to the HADS-A scores, 26.7% of respondents reported borderline anxiety, and 54.4% of respondents reported abnormal anxiety. According to the GAD-7 scores, 39.6% of respondents reported moderate anxiety, 38.6% of respondents reported severe depression, and 12.8% of respondents reported severe anxiety. According to the PSS scores, only 5.9% of respondents reported low stress, whereas 93.9% of respondents reported moderate to high stress. According to the BMWS scores, only 10.8% of respondents reported moderate worry levels, whereas 89.1% of respondents reported high worry levels during the COVID-19 pandemic. These results contrasted with those of other studies,[29] possibly due to the use of different predictors, including the method of pregnancy, family history of psychiatric illness, panic disorder, and predominant thoughts of COVID-19.

However, the current study revealed the high incidence of worry levels in antenatal women, with more than 89% reported being worried that the COVID-19 pandemic may result in a fetal physical irregularity, fetal developmental constraint, abortion, or preterm delivery, despite the performance of supportive ultrasound investigation and other examinations. We also found that worry scores were profoundly higher among individuals with anxiety only compared with those with depression. This result contrasted with a previous study, which reported similar levels of worry between depressed and anxious individuals[30] but was consistent with the findings reported by Chelminski and Zimmerman, who reported higher worry scores among anxious individuals compared with those in depressed individuals.[31] Therefore, the tendency towards increased worry levels might reflect the emotional state of antenatal women.

In this study, the general prevalence of perceived stress, as assessed by the PSS among antenatal women, was observed to be 93.9%, which was much higher than reported by previous studies.[32] This variation is likely due to differences in the sample size, socioeconomic demographic characteristics, discrepancies in the topographical area, and social practices. In our study, other contributing factors may have been that most of the pregnant women were employed, and the majority of them were recently hospitalized with pregnancy complications. We also observed that multiparous pregnant women reported higher perceived stress scores (72.2%) than primiparous women, which may be associated with undesirable previous pregnancy and delivery experiences,[33] which supported the findings of previous studies.[34] Antenatal women, due to strong and significant feelings toward their fetus, might take better care of themselves and adhere strictly to the health recommendations during the COVID-19 pandemic.

However, anxiety in antenatal women may result in detrimental consequences during pregnancy, and the COVID-19 pandemic appeared to have a comprehensive impact on the psychological health of pregnant women, which agrees with the findings of previous studies.[35] COVID-19-associated panic is an important cause of increased anxiety levels during this pandemic, and an extremely common source of fear and anxiety is the fear of COVID-19 infecting loved ones,[36] especially during pregnancy. When examining the GAD-7 results, the majority of antenatal women (91%) reported moderate to most severe anxiety, and the HADS-A indicated that three fourth (81.1%) were categorized as borderline to abnormal anxiety levels, in contrast with the results of a previous study.[37]

A primary concern during this coronavirus pandemic is that most antenatal women experience fear and worry associated with visits to hospitals for both themselves and their extended family members, and this stress, anxiety, depression, and worry, results in a desire to end their gravidities early or by cesarean delivery.

The present study has some limitations. First, the anxiety, stress, and worry levels of partner’s during the gestation of their spouses were not analyzed, nor was the amount of support for their partners during the COVID-19 pandemic period examined, which may be a significant and vital factor for the mental health of pregnant women. Therefore, future studies examining the effects of the father’s anxiety should be explored. Second, there could be chances of false-positive error because multiple exploratory comparisons have been made in the present study. Third, combining different modes of the assessment in the same research (in-person vs. the electronic format) may be challenging, as each method has its pros and cons. Last, the self-reported anxiety, depression, stress, and worry levels assessed by utilizing different scales may not correlate with the results of evaluations by mental health care professionals. Therefore, additional prospective investigations should be performed to examine the effects of these factors on antenatal women’s mental health and pregnancy, to better understand the true effects of the COVID-19 pandemic.

CONCLUSION

The present study results showed that during the COVID-19 outbreak, more than three-fourths of respondents rated their anxiety as being moderate-to-most severe, and approximately 90% reported moderate-to-high stress and worry. The method of pregnancy, recent hospitalization, associated health problems, panic disorder, and current anxiety, depression, stress, and worry factors have significant impacts on pregnant women’s psychological health. Therefore, providing up-to-date health information for improving maternal attentiveness to coronavirus, its risk factors, and its influence on the fetus and baby will be vital to improving outcomes during pregnancy.

Ethical approval

The Ethical Committee of King Khalid University approved the present study protocol (ECM#2020-0909).

Consent to participate

All the participants received a description about the nature and purpose of the study, their rights, and potential risks and benefits of participation before they gave a signed consent.

Financial support and sponsorship

(R. G. P 2/40/42).

Conflicts of interest

There are no conflicts of interest.