Knowledge, attitudes, practices, and influencing factors of anxiety among pregnant women in Wuhan during the outbreak of COVID-19: a cross-sectional study

According to the Chinese Center for Disease Control and Prevention (China CDC), since the identification of the first case of COVID-19 in Wuhan on 8 December 2019, a total of 82,874 confirmed cases of COVID-19 and 4633 deaths due to the disease were recorded at the end of April in China [1]. The disease has then spread to Southeast Asia, Europe, North America, Australia, and the Middle East, leading to the COVID-19 pandemic declared by the World Health Organization (WHO) on 11 March 2020 [2].

COVID-19 is caused by SARS-CoV-2, a new human-infecting betacoronavirus different from SARS-CoV-1 and MERS-CoV [3]. It is spread through respiratory droplets and direct contact [4]. There are only a few cases of pregnant women with COVID-19. It remains unclear whether intrauterine infection can be caused by vertical transmission in women who contract COVID-19 during pregnancy [5‐7]. Limited data suggest that pregnant women with a confirmed COVID-19 infection were similar to their non-pregnant counterparts in the general population with relatively optimistic clinical outcomes [8, 9]. A meta-analysis suggested that pregnant and recently pregnant women are less likely to manifest covid-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for COVID-19 [10]. However, most research has mainly focused on the therapeutic aspects, while pregnant women’s mental health status during the COVID-19 is much less studied.

Prenatal care is vital to a healthy pregnancy [11]. Any non-routine changes to prenatal care could be a stress factor to pregnant women, especially in Wuhan, the first city hit by the virus. Since the outbreak, the Wuhan government has taken several unprecedented precautionary measures. All the suspected or confirmed COVID-19 case with pregnancy were not allowed to visit the maternal hospitals, only designated hospitals. As for maternal hospitals, all prenatal exercise, hospital tours, and prenatal classes were canceled. Mask wearing became mandatory in hospitals. Only routing obstetric and gynecological scans were not called off, and the preparation and cleaning of ultrasound equipment and transducer was in accordance with local guidelines [12]. Antenatal care was available, but the delivery of it was affected. The pregnant women were recommended to reduce the antenatal visit.

Prenatal anxiety has important maternal-fetal implications. It may be associated with preterm birth, fetal growth restriction, and obstetric complications and had enduring effects directly or indirectly on children’s growth and development [13]. Children with a history of in utero exposure to maternal anxiety are at increased risk for various neuropsychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD) [14, 15]. The anxiety level is affected by individual personality, resilience, education level, support from family, satisfaction with life quality, occupation, and financial status [16, 17]. During this pandemic, anxiety may also be affected by individuals’ knowledge, attitudes, and practices (KAP) towards COVID-19 [18, 19]. For example, increased anxiety levels have been reported in countries and cities in the general population and subpopulation with significant outbreaks [19‐21]. But only a few studies investigate the anxiety level and its influencing factors among pregnant women [22‐24]. The study aimed to evaluate the sociodemographic characteristics, KAP, and anxiety level of pregnant women during the COVID-19 epidemic in Wuhan and investigate the affecting factors for prenatal anxiety in this specific context.

The current study showed that pregnant women in Wuhan had good knowledge, attitudes, practices towards COVID-19. Most women paid close attention to the official news on COVID-19 and did not worry about being infected by the transducer. Almost two-thirds of the participants either postponed their antenatal visits or reduced the visits’ frequency as advised by the government. Still, about 10.2% of pregnant women were worried about contracting COVID-19 by the transducer and had high anxiety levels. It is suggested that doctors and nurses should pay more attention to this issue.

The current findings revealed the highest prevalence of anxiety (21.1%) in participants who were in the second trimester, the lowest in those who were in the third trimester (20.7%), and a middle level of anxiety was in those who were in the first trimester (20.9%). These differences are tiny. The general prevalence of anxiety was 20.8%, similar to that in a global study (18.2–24.6%) before the COVID-19 pandemic [30]. However, It was a little different from the previous study that reported that women close to the term are more worried than those who aren’t [30]. Compared with the other cities in China before the COVID-19 pandemic, the prevalence of anxiety in the current study was higher than in Chongqing (15.0%) but lower than in Zhoushan (22.6%) [17, 31]. And literature reported the prevalence of anxiety in Wuhan (24.5%) was much higher than in Chongqin (10.4%) during the pandemic [24]. Meanwhile, Wu and his colleges reported a clinically significant increase in the prevalence of depressive and anxiety symptoms after the declaration of human-to-human transmission [32]. During the remission phase of COVID-19 in southern China, the anxiety rate was 31.2% [33]. Hence, the anxiety level among pregnant women during the outbreak of COVID-19 in Wuhan in our study was intermediate in China generally. It may not be affected a lot by the pandemic and trimester. This was likely due to increased available information and reassurance through social media, healthcare professionals, and primary care. Moreover, prenatal anxiety levels were different from studies, attributed to the study designs [34, 35].

As noted in the statistical modeling, having previous children in the family was the only risk factor among sociodemographic characteristics for prenatal anxiety. It’s consistent with previous studies. The prevalence of anxiety in women pregnant with their second child was relatively high in China [26]. It’s because they were worried about her child and older relatives being infected by Covid-19, leading to an increase in prenatal anxiety, and physical activity changes resulting from pregnancy were significantly correlated with anxiety disorder [36]. However, their fear was not affected by advanced maternal age, complications during the pregnancy, or household income. The reason might be that most of the participants had learned antenatal care knowledge during their last pregnancy. And 94.6% of pregnant women had an senior high school education or above, they were easier to access the correct information. Moreover, the universal coverage of maternity insurance in China has removed concerns about medical expenses [37].

The current study assessed KAP towards COVID-19 that could impact prenatal anxiety. The followings were protective factors for prenatal anxiety, including more knowledge of COVID-19, not worrying much about contracting the virus, not worrying about getting infected by the probe, trusting in official media, and postponed or reduced ANC times. These findings have implied clinical and policy implications as the COVID-19 epidemic continue to spread. Firstly, health administrators should provide accurate and updated information continuously. Secondly, this highlighted the care of pregnant women should be tailored individually for women’s mental health [38].

During the intermediate phase of the COVID-19 outbreak in Wuhan, pregnant women had an overall good knowledge of COVID-19, and anxiety was common. We have identified several influencing factors of prenatal anxiety, which can guide public health strategy regarding pregnant women anxieties.