Background
The outbreak of coronavirus is a global health threat [
1]. Following the global pandemic crisis, the diagnosis of two coronavirus cases in Iran, the city of Qom, was confirmed on February 2020, and the outbreak of the new coronavirus was officially declared on March 2020, covering almost all provinces of the country [
2].
COVID-19 is a beta-coronavirus that can be transmitted through physical contact between humans. According to studies, a person infected with COVID-19 can infect at least four other people with a new infection [
3]. Overall, the hospital admission rate for this disease is 23% and the resulting death rate is 1–2% [
4]. People with underlying diseases have been reported to have higher morbidity and mortality rate [
5].
Pregnant women are one of the most vulnerable groups that require additional precautions against the COVID-19 outbreak [
6]. Changes during pregnancy may increase susceptibility to some intracellular pathogens, particularly viruses, intracellular bacteria, and parasites [
7]. Furthermore, high-risk pregnancies occur when the pregnant mother has underlying problems before or during pregnancy, in which case her physical, psychological, and social vulnerability increases [
8]. The prevalence of high-risk pregnancies in Iran and other countries ranges from 25.6 to 75.6% [
9,
10]. High-risk pregnancies significantly weaken the mother’s immune system and increase the risk of COVID-19 infection [
11].
COVID-19 in pregnancy has been associated with complications such as premature rupture of the membranes (PPROM) and preterm delivery [
12,
13], fetal distress, and fetal growth restriction as a result of maternal hypoxia. The rate of cesarean section is also reported to be 96.4%, possibly indicating that iatrogenic reasons (fear of obstetrics) can also be a factor [
14,
15]. This has resulted in an increase in the number of pregnant women admitted to the ICU during the COVID-19 pandemic [
16]. Therefore, until further data is available, it is recommended that pregnant women, particularly those with high-risk pregnancies, be completely protected from infection. Furthermore, it is recommended that all pregnant women avoid high-risk areas such as hospitals and health centers and have limited physical contact with health care workers, in other words, maintain social and physical distance [
5]. These guidelines are useful for disease prevention [
14]. However, studies have shown that mothers with high-risk pregnancies are more stressed in these situations due to concerns about their own and the fetus’s health, which increases anxiety and depression in high-risk pregnancies [
17]. On the other hand, in high-risk pregnancies, the woman may experience stress due to the lack of access to health services [
18]. As a result, high-risk pregnancy conditions, social distancing while limiting the number of visits to the woman can increase the woman’s stress, anxiety, and worry. During the COVID − 19 outbreak, people may not think clearly or react logically due to high levels of fear and anxiety [
19,
20]. Maternal psychological distress (such as stress, anxiety, and depression) has consequences for both mother and fetus, and has been found to be a risk factor in children and associated with adult neurodevelopmental disorders, such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), schizophrenia spectrum disorders, antisocial behavior, and depressive symptoms [
21]. As a result, it is necessary to cope with the psychological distress caused by COVID-19 in the presence of its prevalence to avoid the side effects of fetal growth and neurodevelopmental disorders [
12,
13].
So far, few quantitative studies have been conducted on the psychological effects of coronavirus outbreaks in the general population [
22‐
24] and pregnant women [
15,
25], and recommendations for receiving remote prenatal care have reduced referrals for prenatal care [
26]. However, no qualitative studies have been conducted to explain the perceptions and experiences of women with high-risk pregnancies receiving maternity care under these conditions. Since cultural and social contexts are not taken into account when conducting quantitative studies, hence individual experiences, human interactions, feelings, perceptions, and thoughts cannot be measured quantitatively [
27,
28]. Women with high-risk pregnancies, on the other hand, are vulnerable populations with numerous health consequences and risks; thus, understanding their perspective on receiving care in the context of the Corona pandemic condition, as well as discovering their stresses and challenges, is critical for appropriate interventions. Given the scarcity of extensive research on the experiences of women with high-risk pregnancies, research on their experiences and understanding of receiving prenatal care, as well as identifying the support they require in the socio-cultural context of Iranian society, appears necessary. As a result, the aim of this study was to explore how women with high-risk pregnancies perceived and experienced COVID-19 pandemic care.
Discussion
In the COVID-19 pandemic condition, women with high-risk pregnancies experience negative psychological responses such as fear, anxiety, and worry, guilt, doubt, confusion, and conflict. They inevitably receive health care, followed by feelings of depression, sadness, and loneliness. In these cases, women adopted thought-based behaviors to protect themselves and their pregnancies from the double risks of the COVID-19 and high-risk pregnancies. Positive effects of the healthcare system’s behavior and environment, on the other hand, were beneficial in converting those negative emotions and behaviors into positive emotions and health-promoting behaviors. As a result of receiving appropriate information, protective behaviors, and empathetic care from healthcare providers, women’s negative emotions are hopefully reduced and replaced by a sense of tranquility and confidence.
This qualitative study contributes to the scientific understanding of how women with high-risk pregnancies experience increased emotional distress in the context of COVID-19. On the one hand, they are distressed by a high-risk pregnancy, while on the other, they are concerned that they or their families may become infected with COVID-19 and suffer the limitations that this entails. Guilt was a recurring emotion for them because they held themselves responsible for their own and their fetus’s health during COVID-19. Consequently, they avoided receiving health services to reduce their risk of developing COVID-19 and comply with the social transit distance; however, when high-risk pregnancy complications occurred, they felt guilty for failing to visit on time. This study also shows that the COVID-19 pandemic has an impact on the health behaviors of mothers with high-risk pregnancies. Some mothers refused prenatal care out of fear of illness and social pressures, while others tried to avoid delaying health care by adhering to health protocols. Many mothers in these situations sought medical attention and managed their emotional stress by employing coping strategies such as positive thinking and faith in God. Furthermore, the study’s findings suggest that, in addition to protecting health care workers from COVID-19, prevention behaviors by health care workers provide comfort to mothers with high-risk pregnancies. In addition, the presence of COVID-19 protective strategies in health care settings reduced the stress of mothers with high-risk pregnancies. Health care providers’ supportive and empathetic behaviors, such as providing appropriate and correct information to mothers with high-risk pregnancies, make them feel good about receiving health services during the COVID-19 pandemic. No matter the conditions of COVID-19, receiving health services, whether in person, by phone, or online, created a feeling of positive wellbeing in mothers with high-risk pregnancies.
Regarding negative psychological responses, Kotabagi writes: “Psychological disorders have doubled during the Corona outbreak. The mortality, high prevalence, and the nature of the COVID-19 pandemic have increased fears, stress, and anxiety globally. Social isolation and its consequences, on the other hand, are significant factors in psychological disorders” [
34,
35]. Also, in high-risk pregnancies, women increasingly feel that due to not receiving adequate care, something life-threatening and harmful may occur to the fetus, which is the psychological outcome of the COVID-19 pandemic [
25].
Evidence suggests that quarantine and social isolation have negative psychological effects on women with high-risk pregnancies, including symptoms of post-traumatic stress disorder, confusion, and anger. According to Katabatic (2020) the average score of anxiety and depression among British pregnant women rises with the peak of COVID-19 mortality and uncertainty about healthcare capacity to control COVID-19. In contrast, receiving useful information from health care providers reduces negative emotions in women with high-risk pregnancies during the COVID-19 pandemic [
34,
36]. In any case, the mental health of women with high-risk pregnancies during the COVID-19 pandemic should not be overlooked [
34]. Negative psychological responses during pregnancy increase the risk of preeclampsia, preterm delivery, and low birth weight [
37], and also anxiety in pregnant mothers can increase labor pain [
38] while providing timely psychological support to high-risk pregnant women during COVID-19 pandemic can be very effective in preventing such negative consequences. Psychological support for mothers with high-risk pregnancies in the face of the Corona pandemic condition requires a special investment by the government, as it has the potential to benefit society greatly in the future [
23,
39]. According to Lebela, social support can alleviate the psychological pressures and concerns caused by COVID-19 [
25].
The study’s findings point to the effects of the COVID-19 pandemic on health-seeking behaviors of women with high-risk pregnancies, as well as the adoption of thought-based behaviors to protect against the double danger of COVID-19 in high-risk pregnancies. In fact, pregnant women’s fear of developing COVID-19 reduced the number of referrals for prenatal care, which was associated with feelings of guilt or doubt. According to the studies, teleconsultation, sometimes referred to as remote consultation or telehealth, refers to providing counseling and health services over the phone, video conferencing, or the Internet, has been shown to improve depression, anxiety, quality of life, and psychosocial functioning, as well as the quality of pregnancy care among pregnant women during the Corona pandemic condition [
40]. Thus, during the COVID-19 pandemic, it is recommended that women with high-risk pregnancies use technology for prenatal care and psychological support [
25]. Also, husband support and peer-assisted training programs can significantly improve antenatal care and physical and mental disorders in women with high-risk pregnancies in areas with limited access to technology [
41,
42]. Receiving at least four phone calls per day from trained peers or health care providers to ensure the pregnant mother’s health status will reduce depressive symptoms in pregnant women [
43].
Similar to the findings of the current study, in another study conducted in New York City, Aleha Aziz (2020) found that many mothers with high-risk pregnancies considered commuting and using vehicles to be a problem. In addition to worrying about the risk of using public transportation, they also complained about the cost of using personal vehicles [
44,
45]. Therefore, to help solve this problem, they suggested using telehealth. They believe that, in addition to reducing the risk of COVID-19, telehealth comes with social and economic advantages in caring for mothers with high-risk pregnancies. This method is an excellent replacement for face-to-face visits in prenatal care and high-risk pregnancies. To ensure adequate access to health services, they recommend adopting a combination of face-to-face and telehealth care methods [
44]. Some researchers, including Rhodes, have proposed using a digital program to replace face-to-face health services in the United Kingdom during the COVID-19 pandemic to improve the quality of prenatal care for women with high-risk pregnancies [
46]. According to the results of the present study, many mothers adapted to the COVID-19 pandemic condition by adhering to the health protocols and preventive behaviors, as well as taking coping strategies such as positive thinking and trust in God while performing prenatal care to maintain their health and that of the fetus. According to research, coping strategies, reliance on spirituality, and risk-control behaviors during pregnancy are all prerequisites for well-being in high risk pregnancy [
47]. The findings of the Koenig (2020) study also illustrate the importance of faith in mitigating the effects of the disease, even in COVID-19 [
48].
According to the findings of the study, health care providers’ behaviors and environment play an important role in the optimal reception of health services during the COVID-19 pandemic. The behaviors aimed at modifying health care services with reciprocal care for staff and pregnant women to prevent COVID-19. A review of the literature reveals that during pandemics, many midwives and nurses continue to practice with passion, interest, and diligence, providing empathetic and supportive care to patients. They strive to provide the best and highest quality care possible. And, in the event of a disease epidemic, provide a suitable environment for the provision of health services to prevent disease [
40,
49]. Because they believe that gaining knowledge and experience is rewarding, and pandemic services allow them to gain clinical experience, confidence, and competence. It also fosters trust and value in patients, their families, and society as a whole. They have a sense of purpose and meaning in their work. Their goal is to provide quality services with the least harm to clients and recipients of health services. In such cases, midwives and nurses use their competencies and creativity to develop better solutions for providing health services to patients cope with health system failures [
49,
50]. Seeing such behaviors in the healthcare delivery system gives women with high-risk pregnancies confidence in receiving healthcare services. The US Food and Drug Administration (2020) also emphasizes the critical role of health care professionals during the COVID-19 pandemic [
51].
Research strengths, limitations, and future research suggestions
The strength of the current study is conducting qualitative research through in-depth interviews with high-risk pregnant women, allowing them to learn about their perceptions and experiences while revealing potential barriers and factors that facilitate obtaining optimal pregnancy care in the context of the COVID-19 pandemic. Many of these aspects are overlooked in quantitative studies. However, the present study has also faced some limitations, including the need to exercise caution when generalizing the findings, which is a limitation of all qualitative research. Another limitation was that only women with high-risk pregnancies had an in-depth interview to extract the findings of receiving prenatal care. As a result, conducting qualitative studies with health care providers is recommended in this field. Also, a study should be conducted to compare prenatal care receipt in low-risk and high-risk pregnancies in the context of the COVID-19 pandemic.
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