Depression and anxiety among pregnant mothers in the initial stage of the Coronavirus Disease (COVID-19) pandemic in the southwest of Iran

In late December 2019, Chinese healthcare facilities in Wuhan, Hubei, China reported numerous pulmonary infection cases with an unknown type, named coronavirus disease 2019 (COVID-19) [1, 2]. The World Health Organization (WHO) declared this disease as a global pandemic on March 11, 2020 [3]. On January 24, 2021, more than 43 million cases with 999,000 deaths were confirmed in the United States of America, and around 98.2 million cases with 2,112,000 deaths were confirmed worldwide [4].

Recent studies have reported that patients with heart failure, cancer, elderly patients with underlying disease, and immunocompromised patients are frail and predominantly susceptible to severe outcomes associated with COVID-19 infection [5, 6]. Due to the pathophysiological and mechanical changes experienced during pregnancy, pregnant women and their fetuses could be a high-risk population and more prone to this infection too [7, 8].

Previous studies revealed the remarkable impacts of infectious disease outbreaks such as severe acute respiratory syndrome (SARS) on psychological distress, including depression and anxiety in pregnant mothers [9]. Moreover, the children of mothers who experience high psychological distress during pregnancy are more likely to have cognitive and behavioral problems and their communication skills are significantly affected [10, 11]. Despite the extensive effect of psychological distress on pregnant women and their children, there is a gap in our knowledge about these distress rates or levels. Additionally, few studies have reported psychological distress in pregnant mothers during the COVID-19 pandemic [12‐14]. Hence, this study aimed to investigate the predicting factors of depression, anxiety, and stress levels of pregnant mothers in the initial stage of the COVID-19 infection in the southwest of Iran.

In total, 540 out of 920 registered pregnant mothers completed the online questionnaire (58.7%). The mean age of participants was 31.4 (± 5.9) years. The median duration of marriage was 7 years, ranging from 1 to 28 years. The median number of pregnancies, including the current one, was 2, ranging from 1 to 8 pregnancies (Table 1).

The majority of mothers had no comorbidity (451; 83.5%), while 59 mothers (10.9%) had one comorbidity, 29 mothers (5.4%) had two comorbidities, and one mother (0.2%) reported three comorbidities. While the first two most common comorbidities were hypothyroidism (42; 7.8%) and diabetes mellitus/gestational diabetes mellitus (31; 5.7%), the least frequent one was idiopathic thrombocytopenic purpura (ITP) reported by one pregnant mother (0.2%). It was found that 167 mothers (30.9%) had been taking medication; of them, 136 (25.1%) were taking supplements including ferrous sulfate, folic acid or perinatal multi-vitamins (Table 2).

Table 3 shows the distribution of symptomatic participants in the DASS subscales based on the participants’ demographic and socio-economic factors. Having an above-normal DASS-D score was statistically associated with the respondent’s insurance status and self-rated health (SRH) level. Hence, an abnormal DASS-D score was significantly higher in pregnant mothers who had no insurance (10.5% vs. 3.9%; p = 0.01). An abnormal DASS-D score was more prevalent among pregnant mothers who reported poor health status (15.6%) compared with those who reported good SRH (6.1%) and intermediate SRH (3.1%). The proportion of abnormal DASS-D was evenly distributed among the remaining demographic and socio-economic factors.

DASS-A was significantly associated with pregnant mothers’ job status (p = 0.01), educational level (p = 0.02), SRH (p < 0.001), and number of comorbidities (p < 0.001). The findings indicated that abnormal DASS-A was more prevalent among employed mothers (32.7% vs. 18%), and those with a university degree (24.3%). Furthermore, mothers who reported their health status as poor had the highest frequency (37.7%) of abnormal DASS-A score compared with those reporting an intermediate SRH (3.1%) or good SRH (6.1%) groups. An abnormal DASS-A level was much more prevalent in respondents with 2 or more comorbidities than in those with one or no comorbidity; 46.7, 25.9, and 16.8%, respectively. No statistically significant differences were found in the distribution of abnormal DASS-A in the variable subgroups (Table 3).

DASS-S was evenly distributed among subgroups of all demographic and socio-economic factors, including maternal age, duration of marriage, number of pregnancies, gestational age, residential area, occupation, educational status, insurance status, income, claimed SES, SRH, and number of maternal co-morbidities (Table 3).

As demonstrated in Table 4, logistic regression analysis showed that an abnormal DASS-D was associated with SRH (p < 0.001) and insurance status (p = 0.03). Pregnant mothers who reported their health status as poor had a higher chance of having an abnormal DASS-D score (OR = 27.8; p = 0.001). Respondents who did not have insurance had a 2.5 times higher chance of having an abnormal DASS-D score (p = 0.03; CI for OR 1.1–5.6).

Table 5 shows those factors associated with an abnormal DASS-A level. According to the logistic regression, mothers with lower SRH had a higher chance of achieving a poor DASS-A score. Hence, those with poor SRH had a 6.9 times higher chance of having an abnormal DASS-A level (p < 0.001; CI for OR 3.5–13.7), while those who rated their health status as intermediate had a 2.3 times higher chance of achieving an abnormal DASS-A score (p = 0.01; CI for OR 1.2–4.4). Furthermore, number of comorbidities was associated with low DASS-A score; respondents who had two or more comorbidities had a 3.7 times higher chance of achieving an abnormal DASS-A level (p = 0.001; CI for OR 1.7–8.2).

The COVID-19 pandemic may contribute to a significant increase in depressive and anxiety symptoms. The results of this study revealed that pregnant women repeated abnormal depression and anxiety levels in the initial stage of the COVID-19 pandemic. They further showed that pregnant mothers who had two or more comorbidities and those with lower SRH had a higher chance of having an abnormal anxiety level. A higher depression level was reported in pregnant mothers who had no insurance. Additionally, depression symptoms were more prevalent in pregnant mothers who had poor health status than in those with good or intermediate SRH. Pregnancy is a significant transition period in a woman’s life, and many physiologic and immunologic changes occur during this period [16]. Psychiatric disorders such as depression and anxiety during pregnancy have been associated with many complications, including preeclampsia, diabetes, premature birth, low birth weight, and postnatal complications [17].

Culture is a set of beliefs held by a group of people representing the way of life for that specific group. Cultural values and socioeconomic elements are firmly associated. Previous studies have confirmed that different cultural orientations play pivotal roles in social behavior such as aggression, anxiety, and depression. Moreover, in most developing countries, a high percentage of people are prone to severe stress caused by poverty, natural hazards, or violence. (Most people in high-income countries are protected against these misfortunes.) These factors have an astonishing effect on mental health. Several countries with different cultures are affected by depression, a common psychiatric disorder [18‐20]. Changes in women's hormone levels may lead to an increased chance of depression progression twice that of men, especially during the reproductive period and pregnancy [21]. Previous studies reported a high rate of psychiatric morbidities such as depression and panic attack during the SARS outbreak in 2003. It may reflect another aspect of the importance of these infectious disease outbreaks and necessitate mental health evaluations during these periods [22, 23].

The current study showed that pregnant mothers who reported poor health status and those with no health insurance, had higher abnormal depression scores than others. In line with these results, Wang et al. reported that poor perceived health was highly associated with depression rates [24]. Ahorsu et al. reported the relationship between mental health and fear of COVID-19 among Iranian pregnant mothers and their husbands. Consistent with the current study, they found that fear of COVID-19 was significantly related to the depression level of Iranian pregnant women and their husbands [25].

Anxiety is another critical public health concern, because it can lead to impairments in social, emotional, and physical functioning, resulting in a higher level of healthcare service utilization [26]. Glover et al. revealed that increased anxiety during pregnancy had a significant relationship with plasma and amniotic cortisol levels [27]. Consistent with the current findings, Lebel et al. and Wang et al. recently reported that pregnant women had clinically elevated pregnancy-related anxiety symptoms during the COVID-19 pandemic [12, 24].

Conversely and inconsistent with the present study, Wu et al. and Durankus et al. reported that low education level was a common associated at-risk factor for depression progression and anxiety symptoms during the COVID-19 pandemic [17, 28]. The current results revealed that an abnormal anxiety level was more prevalent among pregnant mothers who had university degrees. This may be explained by the fact that pregnant mothers with a high level of education had more awareness about this pandemic's threat and consequences; thus, they are more affected mentally than low-educated pregnant mothers.

The current study had several limitations. First, this study was cross-sectional and we could not show the long-term effects of depression and anxiety levels on maternal and neonatal outcomes. Second, pregnancy is a physiologic condition accompanied by anxiety and stress due to hormonal changes as well as facing a new circumstance, and we could not differentiate the contribution of pregnancy and COVID-19 pandemic in higher levels of anxiety and stress reported by participants. However, former researchers have mentioned that these levels had been increased compared with the pre-COVID-19 pandemic era [12]. Moreover, the current study was conducted only in Shiraz, one of the largest cities in Iran, so the results cannot be generalized to the whole of Iran.

This study had some strengths as well. One of the strongest points of this study is that it was conducted during the first months of the epidemic. Therefore, it reflects the real stress and anxiety of expecting mothers. Moreover, this topic had not yet been addressed in Iran during the COVID-19 pandemic. Another positive aspect of this study is that women felt more comfortable about expressing their anxiety and depression symptoms on the self-administered questionnaire used herein.

The current study results revealed that the COVID-19 pandemic may contribute to a significant increase in depression and anxiety symptoms among pregnant mothers. Moreover, a lack of insurance, poor SRH, and the existence of comorbidities are significantly associated with increasing depression and anxiety scores. Screening for psychological disorders such as depression and anxiety, especially in pregnant women, and well-known communication with consistent and precise updates about the COVID-19 pandemic should be provided as a disease-preventive plan for intellectual and cognitive well-being.