A survey of the psychosocial impact of the COVID-19 pandemic on pregnant women attending a tertiary care centre of Eastern India – a cross-sectional study

Introduction

The COVID-19 pandemic, which began in December 2019 and has continued to spread worldwide throughout the last 2 years, has not just led to the loss of human life but also presented an unprecedented challenge through widespread social disruption. Billions of people have faced restrictions due to varying degrees of confinement such as banning public transport, restricting movement, and imposing a 14-day quarantine after travel [1]. Prolonged periods of isolation, bereavement, and losses of jobs and incomes have had a huge impact on the mental wellbeing of people. Pregnant women are particularly affected because they are naturally concerned about the safety of their baby and existing children. Pregnancy-related shifts in sex steroids and monoamine neurotransmitter levels, dysfunction of the hypothalamic pituitary-adrenal axis, thyroid dysfunction, and alterations in immune response are all associated with an increased risk for mood disorders [2]. Anxiety, sleep disorders, and functional impairment are common [3, 4].

During SARS outbreak in 2002, a substantial proportion of pregnant women overestimated their risk of infection, which led to increased fear and anxiety among them [5, 6]. Such fear and unwarranted anxiety resulted in adverse effects on both the foetus and the mother, as well as to unnecessary interventions like premature terminations and abortions. Also, there were countless misconceptions and misapprehensions, especially in backward and rural societies. Large-scale propaganda was undertaken to spread correct information regarding COVID-19, and stringent safety measures were incorporated, but they were mostly generalised, and information aiding the psychological stress on the masses came much later. The aim of our study was to assess the psychosocial impact of the current pandemic on pregnant women, which in turn reflects the awareness among them of the effect of the infection on pregnancy. This study would also help us to analyse the extent and effect of the anti-pandemic activities in alleviating the fears and anxieties of special populations and also to find lacunae so that better informed decisions can be taken to spread targeted awareness to support not just the physical but also the mental well-being of the population in the current as well as future pandemics.

The primary objective was to measure the anxiety level of pregnant women during the COVID-19 crisis. The secondary outcome was to assess the correlation between various demographic aspects of the pregnant women and the psychosocial impact of the COVID-19 pandemic on them.

Material and methods

Results

A total of 292 women were assessed during this study. The age of women included was 18–50 years with a mean age of 27 years. Most of our study population (72.3%) were from rural areas, and only 7.2% were employed. Fifty-six per cent of the women were of high socioeconomic status. The majority, i.e. 96.6% of the women, followed Hinduism (Table 1).

Of the 292 women, 179 (61.3%) were nullipara, and most of them (96.6%) were in their third trimester. Only 5 (1.7%) had a recent travel history, and 22 (7.5%) claimed to have had contact with a suspected/confirmed COVID-19 case (Table 1).

More than half the participants (57.9%) said that they were not at all worried about acquiring the infection. Very few of them expressed their worry of stigmatisation and facing arguments in the community as somewhat and moderate (around 8–20% and 1%, respectively) whereas none of them were very much worried. Most of them were found to be not at all worried regarding the place or mode of delivery (77.4% and 70.2%, respectively) (Table 2).

During the pandemic, with respect to their ease of access to basic daily necessities, nutrient-rich foods, and medications, only around 1–2% reported that they were worried moderately or very much. A large proportion (97.6% and 99.7%) were not at all worried about their inability to satisfy food cravings and water contamination, respectively (Table 2).

Among 113 (38.7%) multipara women, 23 (15.2%) agreed to being worried regarding transmission to existing children. With the pandemic restriction, most participants (more than 80%) confessed to being worried due to decreased social activities, social contact with friends, and intimacy with their partners. Regarding being affected economically, half of the women expressed no worry, and the rest were found to be worried, with most (35.6%) being somewhat worried (Table 2).

With regards to management of pregnancy if affected with COVID-19 in the antenatal period, the majority of the women (more than 50%) felt that it was unknown. Around 20% were aware that pregnancy can be continued, and 12% and 9% believed termination of the pregnancy was warranted when infected before and after 13 weeks of gestation, respectively (Table 3).

Generalised anxiety disorder scoring was used to assess the anxiety levels of the study participants. Out of the 292 study participants, 99.3% were scored to have no anxiety and 0.7% had moderate anxiety.

On assessing the association of anxiety (GAD score) with variables like demographic profile, travel history, contact with suspects or cases, and reduced social activity, significant association was found with living with people at high risk of contracting the disease (p = 0.002). These women were mostly health care workers or were living with one and had moderate anxiety on GAD-7 scoring (Table 4).

Discussion

There have not been many studies exploring the psychosocial and behavioural impact of pandemics on pregnant women, especially from rural backgrounds. Stressors like movement restrictions, widespread lockdowns, and curfews, reduced social activities, financial crises, safety of existing children, and difficulty in access to routine care in this sensitive time of their lives can have different outcomes in different pregnant women. As public awareness and accessibility to reliable information has been improving, the behavioural patterns of the people have changed. Hence, our results, though similar, have some differences from past studies and studies in other countries.

Having been conducted in a tertiary care centre in eastern India, which caters to patients from all over the state of Odisha and border areas of adjacent states, our study population mostly (72.3%) had a rural background but good education (75.7%). Conversely, a similar Indian study by Jelly et al. and a Spanish study by Puertas-Gonzalez et al. included a more urban population with good educational status [7, 8]. Similarly, the studies by Hashim et al. [9], Guner et al. [10], Hübner et al. [11], and Diamanti et al. [12] were on a more educated and urban population.

Owing to the extensive and far-reaching campaigning by the government, more than 80% of our women were not at all worried about getting infected, or facing arguments or stigmatisation in their society. Teleconsultation facilities, online appointments for antenatal check-ups, multiple psychiatry helplines by hospitals, and availability of most consumables via mobile shops and 24/7 pharmacies ensured that more than 70% of our participants were not all worried, indicating a zero to mild psychosocial impact of the pandemic on them. Similar observations were made in one of the first studies of this kind in the United Arab Emirates [9], in Bosnia, Herzegovina, and Serbia [13], and Germany [11] by Hübner et al., who used the Edinburgh Postnatal Depression Scale and Anxiety Sensitivity Index. Whereas comparable studies in Italy (2020) [14], China (2020) [15], and Greece (2023) [12] reported moderate to severe psychological impact on their participants calculated using the Impact of Event Scale-Revised Score and State Anxiety Inventory (STAI) scale, respectively.

More than 90% of our participants expressed mild worry with regard to their social lives being affected by the pandemic. With ample support from family members, the study of Hashim et al. reported comparable findings [9]. Relatable findings were made in the studies by Hübner et al. [11] and Diamanti et al. [12], which showed low levels of fear among the study populations. On the other hand, a similar study in the past in Hong Kong by Ng et al. during the SARS epidemic reported moderate to severe worry in pregnant women due to their reduction of social activities [16]. This depicts the stark difference in the effect of previous outbreaks on the mindsets of the population.

We used GAD-7 scoring to assess the level of anxiety in the women included. Almost all women were found to have no anxiety as per the scoring system, but the few participants (0.7%) who were found to have moderate anxiety were health care workers. Similarly, in another Indian study, minimal anxiety levels were observed using the same GAD-7 scoring [7]. Comparatively, a study conducted on health care workers using GAD-7 scoring, like us, revealed mild-moderate anxiety among its participants [17]. Conversely, in the study by Saccone et al. anxiety scoring was done using Spielberger STAI, and most women (> 65%) were found to have moderate anxiety [14]. Also, Preis et al., using GAD-7 scoring reported moderate-severe anxiety in more than 40% of pregnant women [18].

We compared anxiety levels with participants’ education, socioeconomic status, employment status, residence, parity, gestational age, decreased social activity, recent travel and contact with suspect/confirmed cases, and when living with people at high risk of infection. We found significant association between anxiety score and having high-risk family members (p = 0.001). In the Italian study, significant association was found with visual analogue scale for vertical transmission of disease, which resulted in most women opting for cell-free foetal DNA testing in their first trimester [14]. Jelly et al. reported that anxiety levels were significantly associated with education, residence, awareness about COVID-19, monthly income, as well as marital and family support [7]. Preis et al. found that high-risk pregnancy, preparedness stress, and perinatal infection stress independently predicted a greater likelihood of moderate to severe anxiety [18]. In the study by Puertas- Gonzalez et al. higher levels of anxiety were seen in women who were infected during pregnancy compared to those who were not [8].

Conclusions

Infectious disease outbreaks, especially pandemics, throughout history have not just affected people physically and economically but have also had huge impacts on their social lives and psyche. There have been multiple advisories, advertisements, and campaigns regarding behavioural practices for disease prevention but not many addressing the psychological aspect of the disease on the people. In pregnant women, who are already vulnerable due to their physiological condition, pandemics and the panic surrounding them can have a much greater impact, especially the stress of perinatal infection and transmission to existing children. In such a scenario, the role of health care workers becomes much more important, wherein they need to provide medical service and bust myths and provide reliable information to the pregnant women.

The change in the effect on people from panic in the previous pandemics to assurance in the current one, as found in our study, indicates the commendable work done to spread well-founded information far and wide by the government, health care institutions, and workers. Publication of more studies of this kind, especially from less affluent and educated populations, can have a great influence on policy makers in directing future awareness strategies, resulting in a sense of 100% security and safety among all.