Prenatal anxiety and the associated factors among Chinese pregnant women during the COVID-19 pandemic——a smartphone questionnaire survey study

Pregnant women experience considerable physical and psychological changes in the process of pregnancy, which may elevate their likelihood of suffering from mental disorders [1, 2]. Since December 2019, pregnant women have had to experience the Coronavirus disease 2019 (COVID-19) outbreak [3], which may detrimentally impact their psychological health. The uncertainty of the COVID-19 pandemic brought about not only the risk of morbidity and mortality caused by COVID-19, but also resulted in mental disorders among pregnant women, such as symptoms of anxiety, panic, depression, and post-traumatic stress disorder (PTSD) [4‐6].

Pregnant women may cancel or delay obstetric examinations because of worries about the risk of SARS-CoV-2 infection at health facilities, routine inspection and the process of delivery [7, 8]. The fear of infection brought about excessive burdens for women and presumably exacerbated symptoms of anxiety which has been found to be prevalent in pregnancy [9]. According to the previous studies, approximately 8.3–57.0% of pregnancy suffered from high anxiety prevalence during the COVID-19 pandemic [10‐13]. Anxiety may have inimical consequences on the outcomes of pregnancy, increasing the risks of preeclampsia, nausea and vomiting, resulting in preterm labor or miscarriage and reduced quality of life [14, 15]. Furthermore, it may also result in adverse effects on the newborns including low birth weight, negative infant temperaments, and adverse neurodevelopmental outcomes [16].

Factors that influence pregnant women’s psychological state are complicated and multifaceted. Demographic characteristics and characteristics of pregnancy such as monthly income and vomiting were found to be associated with prenatal anxiety [8, 17]. Pregnant women who have had financial strain and suffered from vomiting, especially hyperemesis gravidarum, reported a deterioration of their physical and mental health, which increased their perception of anxiety [18, 19]. Besides the well-documented perinatal risk factors, social cognitive model indicated that general public’s assessment of cognitive processes and emergencies directly affect their emotional responses [20]. Based on the social cognitive model, worry about SARS-CoV-2 infection may be a crucial predictor associated with increased anxiety rates in pregnant women [21]. Meanwhile, the conservation of resources theory suggests that restoration of resources, such as medical care, can mitigate the consequences of large-scale traumatic events and has been shown to be the most influential predictor in reducing post-traumatic stress [22].

Self-efficacy, as a positive resource, is defined as the perceptual ability to execute and perform required actions in order to achieve a specified type of performance, which plays a vital role in the transition into motherhood and has a strong relationship with reduced anxiety [23, 24]. As the motivation of individual self-continuous adjustment and a reflection of a positive state of mind, self-efficacy functions as a vital part in the transition into the role of motherhood and the reduction of anxiety [25]. Pregnant women who have high levels of self-efficacy can more easily confront psychological pressure and actively seek effective ways to solve problems when they encounter challenges. A growing body of research illustrates that self-efficacy acts as a buffer to daily stress, which contributes to greater psychological well-being and physical health [26, 27].

There is an urgent need to explore the mental health among pregnant women during COVID-19 pandemic. The target of this study was to assess the levels of prenatal anxiety and its associated protective and risk factors during the COVIID-19 pandemic, including demographic characteristics, symptoms of pregnancy status, and positive resource, as well as the pandemic of COVID-19. This study provides evidence that can be used to improve psychological counseling and psychological crisis interventions for pregnant women.

The study demonstrated the impacts of the COVID-19 pandemic on the prevalence of prenatal anxiety among 304 pregnant women in Shenyang, the capital city of Liaoning province, China. The results revealed that 11.18% pregnant women experienced prenatal anxiety during the COVID-19 pandemic (GAD score ≥ 7), which was slightly higher than the prevalence before the pandemic according to the previous studies (4% VS 7%) [33, 34]. Previous surveys also indicated that the degree of anxiety in the presence of the COVID-19 pandemic among pregnant women in Shenyang was slightly lower than that of those who lived in Wuhan (24.5%), U.S. (22.7%), Canadian (36.2%), Sri Lanka (17.5%), but was higher than those who lived in Chongqing (10.4%) [6, 10, 35, 36]. The possible reasons might be due to Shenyang being in a low-risk area for SARS-CoV-2 [37]. Additionally, the Chinese government provided timely information and conducted universal education on prevention and control measures to enable the public to correctly understand the COVID-19 pandemic and its transmission route [38]. Various hospitals provided convenient timely medical access for pregnant women, including reduced waiting times for prenatal care which also lessened crowding at medical facilities [39], which might make pregnant woman feel more secure and thus, decrease the symptoms of anxiety. In addition, this study conducted from April to May 2020, when the epidemic prevention and control in China had achieved national recognition, which may have helped alleviate pandemic-related fear for the general public.

This study revealed that high monthly income was a protective factor of pregnant women’s prenatal anxiety, which was consistent with previous studies [40]. Having a higher monthly income might result in a reduced impact of the COVID-19 pandemic on the women’s daily life and could facilitate access to higher-quality medical resources [18]. Additionally, pregnant women with low monthly income may not receive adequate attention from their families due to financial deprivation, resulting in relatively low access to health services and even a lack of prenatal care during the COVID19 pandemic, which might trigger anxiety [35].

Notably, vomiting was found to be a risk factor for prenatal anxiety. Women with a history of severe vomiting were susceptible to have psychological disturbances, such as anxiety and depression [41]. Vomiting may act as a physiological response to overwhelming stress and therefore pregnant women with vomiting symptoms may be more likely to experience anxiety when they were not able to cope effectively with stress caused by the epidemic of COVID-19 [42]. Pregnant women who have less pregnancy experience and more sensitive may easily magnify pregnancy symptoms such as nausea, vomiting into a more serious illness, or even be associated with COVID-19 infection, which finally enhance prevalence of anxiety. This finding was consistent with a prospective case-control study, which demonstrated that the degree of anxiety in women with pregnancy with symptoms of vomiting was higher than that among non-vomiting pregnant women when suffered from elevated stress [41]. Thus, vomiting symptoms should be monitored as a regular obstetric examination. High-quality prenatal care and long-term follow-up should be provided for the pregnant women with pregnancy-related complications to promote early diagnosis and attenuate the levels of anxiety during the COVID-19 pandemic.

The results of this study indicated that pregnant women who perceived susceptible to SARS-CoV-2 infection were prone to have higher levels of prenatal anxiety. Among our participants, 13.5% of women reported feeling very possible about SARS-CoV-2 infection. Given the common modalities of routine examination, pregnant women were afraid of being exposed to hospitals where there were relatively high cases of COVID-19 patients. Besides, with the uncertain features of the COVID-19 virus and symptoms, the excessive concerns and worries about their own health and vertical mother-to-fetus transmission infection might have increased the prevalence of anxiety [21]. In addition, fear of discrimination infectious diseases increases people’s concern for infection and drives adverse psychological impacts, which could finally result in elevated levels of anxiety [43]. This finding was consistent with a study of 2740 American prenatal women form 47 states and a survey of 4142 prenatal women from 10 provinces in China, which both demonstrated that the more worried about COVID-19 pandemic, the more severe their anxiety would become [17, 44]. Thus, appropriate intervention on mental health management through disseminating accurate information and providing health guidance is crucial to alleviate the risk of inaccurate perception among pregnant women and prevent from the development of anxiety during the COVID-19 pandemic.

Another finding of our survey was that satisfaction with medical services serves as a protective factor against prenatal anxiety. The majority of pregnant women (260/304, 85.5%) reported they were satisfied with medical services, which implied that the quality of prenatal care improved and the expectations of pregnant women’s health were met during the COVID-19 pandemic. Chinese pregnant women were satisfied with local health facilities due to the effective measures to facilitate prenatal care, such as prompted interpreted the guidelines through new media to popularized professional knowledge, launched online education to answer questions, opened online appointments and green channels [39]. Pregnant women who were satisfied with their medical care tended to report experiencing warmth, security, and easier access to medical services, which might attenuate the impact of potentially adverse psychological effects due to the COVID-19 pandemic, such as anxiety. Our finding was consistent with a survey including 100 cancer patients showing that satisfaction of medical care not only influenced the compliance of patients and reduced disease-related stress and the prevalence of anxiety, but also impact the treatment outcomes [45]. Therefore, this research provides evidence-based evidence that all pregnant women should be provided with access to high-quality prenatal care during the pregnancy.

Finally, our findings illustrated that self-efficacy played a positive role in relieving anxiety, which is consistent with previous studies [25, 27]. Self-efficacy can buffer the effects of stressful life events by enhancing the ability to combat the stressors [46] . Pregnant women were susceptible to perceive additional stress in the COVID-19 pandemic. High degrees of self-efficacy might help pregnant women seek social support from their family, friends, and physicians, which finally recover quickly from the detrimental influence of the COVID-19 pandemic [47, 48]. Previous study also found that enhance the level of self-efficacy among pregnant women were prone to promoting mental well-being and combating psychological distress during the COVID-19 pandemic [17]. Therefore, psychological interventions promoting self-efficacy should be provided for pregnant women to enhance their confidence during the process of pregnancy and reduce their anxiety.

Our study revealed that there is a slightly high rate of prenatal anxiety among Chinese pregnant women in COVID-19 pandemic (11.18%). Pregnant women who suffered from vomiting and perceived susceptible to SARS-CoV-2 infection experienced the elevated levels of prenatal anxiety. Moreover, high monthly income, satisfaction with medical care, and self-efficacy were found to be protective factors against prenatal anxiety for pregnant women. This study indicated that interventions aiming to target reactions including improvement of self-efficacy, provision of high quality prenatal care and management of pregnancy-related complications are of significant importance to alleviate anxiety among pregnant women while they are encountering public health emergencies.