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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 3  |  Page : 266-272

Psychological burden of coronavirus disease 2019 pandemic among Egyptian pregnant women


1 Department of Obstetrics and Gynaecology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Psychiatry, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
3 Department of Community and Occupational Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt

Date of Submission23-Nov-2021
Date of Decision17-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Hala W.A Halim
MD of obstetrics and gynecology , Faculty of Medicine for girls .Al-Azhar University, 295 Seket Elwayly Street, Hadaek El Kobba, Cairo, 11646
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/azmj.azmj_133_21

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  Abstract 


Background and aim Pregnant women are more prone to psychological distress, which can have a deleterious effect on the mother and the fetus. coronavirus disease 2019 (COVID-19) pandemic is a new and dangerous event with limited data available that may adversely affect the mental health of pregnant women. So, the aim of this study was to assess the psychosocial effect of the COVID-19 pandemic on pregnant women, pregnant women’s perceptions toward COVID-19 epidemiology, and antenatal care service utilization during the pandemic.
Patients and methods This cross-sectional study was carried out in the interval from February 2021 to September 2021 and included 340 Egyptian pregnant women with singleton pregnancy during the COVID-19 pandemic. A structured self-administered online questionnaire was completed by the participants. The validated 21-item Depression, Anxiety, and Stress Scale-21 was used.
Results The study revealed a high prevalence of stress (61.5%), anxiety (73%), and depression (68.5%) among pregnant women. Chronic diseases, irregular antenatal care, and previous COVID-19 infection of family members were all significant predictors of anxiety and depression. In contrast, prior infection of the pregnant women with COVID-19 in the current pregnancy was a significant predictor for stress, anxiety, and depression.
Conclusion There was a high prevalence of anxiety, depression, and stress among Egyptian pregnant women during the time of the COVID-19 pandemic. Psychosocial support is required, in addition to raising pregnant women’s awareness regarding COVID-19 infection.

Keywords: coronavirus disease 2019 pandemic, Egyptian pregnant women, psychological burden


How to cite this article:
Halim HW, Abd Elaziz SY, Fathy DS. Psychological burden of coronavirus disease 2019 pandemic among Egyptian pregnant women. Al-Azhar Assiut Med J 2022;20:266-72

How to cite this URL:
Halim HW, Abd Elaziz SY, Fathy DS. Psychological burden of coronavirus disease 2019 pandemic among Egyptian pregnant women. Al-Azhar Assiut Med J [serial online] 2022 [cited 2023 Jan 27];20:266-72. Available from: http://www.azmj.eg.net/text.asp?2022/20/3/266/358035




  Introduction Top


The coronavirus disease of 2019 (COVID-19) has rapidly spread worldwide in the first months of 2020, and it is now acknowledged as an unprecedented pandemic [1]. By October 4, 2021, there have been 306 798 confirmed cases of COVID-19 with 17 436 deaths in Egypt [2]. The health effects of this virus are heinous, and its psychological and social consequences may be equally damaging [3].

Physiological changes during pregnancy are also associated with psychological changes, especially in the first pregnancy [4]. Such psychological changes are likely to have adverse effects on the mother and fetus. Studies have shown that preterm labor, preeclampsia, and low birth weight are common complications for anxiety, stress, and depression during pregnancy [5],[6],[7],[8]. In addition, delayed neuropsychiatric development may occur in children born to mothers experiencing stress [5].

People are more susceptible to stress and anxiety during pandemics, such as COVID-19, because the course and effects of the disease are unpredictable; depression may coexist with or predispose to this. Such psychological disturbance may be exacerbated in pregnant women, being more vulnerable both antenatally and postpartum [9].

Several studies have been performed worldwide demonstrating a high prevalence of psychological disturbance among pregnant women because of the COVID-19 pandemic. For example, a study performed in Turkey discovered an increased level of depression and anxiety among pregnant women during the pandemic [10]. Another study conducted in Italy revealed that about two-thirds of the participant had anxiety, and more than half reported psychological effects of COVID-19 [11].

To our knowledge, there have been few studies on the psychological effect of the COVID-19 pandemic among pregnant women in Egypt. Consequently, our study aimed to determine the prevalence of stress, anxiety, and depression in Egyptian pregnant women during the COVID-19 pandemic and their perception of COVID-19 threats and epidemiology.


  Patients and methods Top


Study design and setting

This cross-sectional study was conducted over a 9-month period (from February 2021 to September 2021) among Egyptian pregnant women with singleton pregnancies during the COVID-19 pandemic. Those with a history of psychological disorders or known fetal congenital anomalies in the current or previous pregnancies were excluded.

Sampling technique

A convenient sample of 340 pregnant women was included using electronic platforms, that is, WhatsApp and Facebook, to allow interested respondents to access questionnaires. This was based on the WHO’s COVID-19 prevention guidelines of physical distancing.

The sample size was calculated using the Cochran formula for cross-sectional studies at a 95% confidence level and 5% error margin. The expected prevalence was estimated anxiety and depression from a published systematic review.

Data collection tools

Each participant completed a structured self-administered questionnaire using the attached link on the Google form. This questionnaire was designed to collect the following data:
  1. Demographic characteristics of pregnant women, that is, maternal age, residence, level of education, current working, the relation of work to the health sector, and income during the pandemic.
  2. Medical history, that is, if participants had a chronic illness, had previously had COVID-19, or any of their family members.
  3. Obstetric history, that is, gestational age, parity, planning for current pregnancy, mode of delivery in previous pregnancies, history of abortion or complications in the previous conception, regularity in antenatal care, and availability of supplementation.
  4. Pregnant women’s perceptions of COVID-19 threats to mother and fetus, namely, the liability to transplacental transmission and risk of causing congenital anomalies, measured using a subjective item categorized in three levels: agree, disagree, and neutral.
  5. Assessment of psychological burden of COVID-19 on pregnant women to measure the prevalence of stress, anxiety, and depression using the 21-item validated Depression, Anxiety, and Stress Scale (DASS-21). It is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress. Each of the three DASS-21 scales has seven items, divided into subscales with similar content. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest, anhedonia, and inertia, whereas the anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale evaluates difficulty relaxing, nervous arousal, easily upset/agitated, irritable/overreactive, and impatience.


The responder has to select one of four answers, ranging from ‘did not apply at all’ to ‘apply very much.’ Higher scores indicate severity. Scores for the three scales are calculated by summing the scores for the relevant items. The following are the recommended cutoff scores for conventional severity labels (normal, moderate, and severe), with scores multiplied by two to calculate the final score ([Table 1]).
Table 1 Depression, Anxiety, and Stress Scale interpretation and categories

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The reliability of the DASS-21 in this study population was α=0.938. The subscales had good internal reliability (Cronbach’s α values of 0.868 for the depression subscale, 0.820 for the anxiety subscale, and 0.856 for the stress subscale) as well as strong convergent and discriminant validity [12],[13]. The Arabic version of this tool has been psychometrically validated [14].

Pilot study

On ∼10 respondents who were excluded from the primary study sample, a pilot study was conducted to test the clarity of the questions and estimate the time required to complete the instruments. The pilot study revealed that the tools did not need to be modified.

Ethical consideration

Administrative approvals: the implementation of this research required the approval of the Research Ethics Committee of the Faculty of Medicine for Girls, Al-Azhar University.

Participants consent: only those who agreed to participate in the study after being informed of the study objectives before completing the questionnaire form were included in the study, ensuring that no physical or emotional harm occurred. Participants were assured of anonymity and confidentiality, and they were informed that the collected data would only be used for research purposes.

Statistical analysis

Data were revised, and potential errors were identified by frequency distribution. Precoded data were statistically analyzed using the Statistical Package of Social Science Software program version 22 (IBM-SPSS; IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. 22). Descriptive statistics for qualitative data were presented by frequencies, percentages, and component bar charts. Comparison between groups was made using the Pearson χ2 test for qualitative data. In addition, multivariate analysis by binary logistic regression predicted stress, anxiety, and depression. P value was taken at the predetermined threshold probability, the significance level of 0.05, and the 95% confidence limit. The results were deemed statistically significant if the P value was less than or equal to 0.05.


  Results Top


This study included 340 pregnant females recruited during the COVID-19 pandemic, approximately half of them were aged 26–30 years, two-thirds resided in urban areas, and the majority were highly educated. Moreover, approximately half were currently working (80.8% were working in the health sector), and 37.1% had income shortage ([Table 2]). In terms of medical history, one-fifth of the participants had a chronic disease, primarily bronchial asthma; 17.1% had a history of previous COVID-19 infection during the current pregnancy; and 40% had an infection in family members ([Table 3]).
Table 2 Demographic profile of the pregnant women

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Table 3 Medical history of the pregnant women

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Approximately half of the pregnant women were in the third trimester, two-thirds were multipara, and 58.2% planned for this current pregnancy. Approximately one-third had a history of abortion, and 14.4% reported a history of complications in previous pregnancies. In addition, 78.8 and 75.6% reported regular antenatal care and accessibility to supplementation ([Table 4]).
Table 4 Obstetric history of the pregnant women

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[Figure 1] demonstrates that nearly half of the participants perceived more risk to infection by COVID-19 than nonpregnant, more risk during antenatal visits at clinics or hospitals, and more safety to the mother and fetus from getting the infection by only restriction to protective measures. However, only 8.5% perceived more risk of transmission of COVID-19 to the fetus through the placenta, and 4.4% perceived more risk of fetal congenital anomalies if the mother is infected.
Figure 1 Perception of the pregnant women toward COVID-19 threats on mother and fetus. COVID-19, coronavirus disease 2019.

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The study revealed a high prevalence of stress (61.5% with severe to extremely severe stress of ∼28.3%), anxiety (73% with severe to extremely severe anxiety of about 46.1%), and depression (68.5% with severe to extremely severe depression of about 30.9%) among the pregnant women ([Table 5]).
Table 5 Prevalence of stress, anxiety, and depression among pregnant women during coronavirus disease 2019 pandemic

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[Table 6] depicts that 54.5, 52.2, and 52.8% of pregnant women who experienced stress, anxiety, or depression, respectively, were in the third trimester, with no statistically significant difference.
Table 6 Distribution of stress, anxiety, and depression according to gestational age of pregnant women

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In the multivariable-adjusted regressing model, urban residence was a significant predictor of stress, low anxiety education, and a lack of income for depression. In addition, suffering from chronic disease, irregular antenatal care, and the previous infection of family members by COVID-19 were significant predictors for both anxiety and depression. In contrast, previous infection of the pregnant female in the current pregnancy by COVID-19 was a significant predictor for stress, anxiety, and depression ([Table 7]).
Table 7 Logistic regression for predictors of risk factors of stress, anxiety, and depression among pregnant women during coronavirus disease 2019 pandemic

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  Discussion Top


COVID-19 is rapidly spreading throughout the world. During the high prevalence of pandemics, different groups of the population, including pregnant women, are exposed to high levels of psychological distress in anxiety, depression, and stress, which can adversely affect mother and fetus. Therefore, one of the aims of our study was to investigate the psychological effect of the COVID-19 pandemic among Egyptian pregnant women.

The results of our study revealed that 61.5, 73, and 68.5% of the participants had stress, anxiety, and depression, respectively, with variable degrees ranging from mild to extremely severe.

These percentages were higher than other studies that assessed the symptoms of anxiety and depression among pregnant women during the COVID-19 pandemic in different countries, such as Lebel et al. [15] in Canada, who found that more than half of their sample (57.0%) reported anxiety symptoms with 37% reported clinically relevant symptoms of depression. Additionally, the study of Parra‐Saavedra and colleagues conducted in Colombia revealed that 50.4% of the entire cohort had anxiety symptoms and 25% reported depressive symptoms. Another study performed by Saccone et al. [16] in Italy concluded an overall incidence of anxiety in two-thirds (68.0%) of the sample. In an Iranian study, Effati-Daryani et al. [17] observed depression, stress, and anxiety symptoms in 32.7, 32.7, and 43.9% of the participants, respectively, with varying degrees from mild to very severe.

The findings of our study, as well as the findings of other studies, can be attributed to differences in patients’ risk perception related to cultural context and social support. Variation in accessibility of health services and health education programs introduced in different countries to alleviate the panic about this new pandemic and provide more safety for pregnant women are also significant factors.

An Egyptian study conducted by Ahmed et al. [18] compared the psychological distress associated with the COVID-19 pandemic in pregnant (60 participants) versus nonpregnant in Kafr El Sheikh Governorate. The study found that 15, 18.3, and 100% of the pregnant women had anxiety, depression, and stress, respectively, which is lower than our findings regarding anxiety and depression. This finding can be attributed to our larger sample size. Furthermore, 80.8% of our working participants were related to the health sector being in contact with cases of COVID-19, observing complications and fatality from the disease every day. Moreover, one-fifth of our participants were chronically ill, and 37.1% lacked income for medical care. Moreover, approximately half perceived more risk to infection by COVID-19 and elevated risk of infection during antenatal visits.

By comparing the current study’s findings with those of other prior studies, we noticed a higher prevalence of adverse psychological effect during the pandemic. A systematic review and meta-analysis done by Dennis et al. [19] concluded that the overall prevalence for any anxiety disorder during pregnancy was 15.2%. Furthermore, the prevalence of perinatal depression was 11.9%, as reported by Woody et al. [20]. Our finding is probably owing to the morbid nature of COVID-19 and its increasing mortality rate, in addition to the lack of high-efficiency vaccines and specific treatment and unpredictable effects on the mother and fetus.

It is highly beneficial to determine the predictors of such psychological disturbance among those women. Our study revealed that chronic medical disorder, low education, shortage of income, irregularity in antenatal care, and previous infection of the participant herself or one of her family members by COVID-19 are common predictors for either stress, anxiety, or depression.

The predictors vary between different studies, whereas others did not consider predictors. Lebel et al. [15] found that depression and general anxiety symptoms were directly related to worries of COVID-19 (threat to life, harm to baby, and not getting needed care) and feeling of isolation. At the same time, loss of employment had no effect. On the contrary, Effati-Daryani et al. [17] found that high level of education of the husband is directly related to depression, anxiety, and stress, whereas marital life satisfaction is inversely related to them. They demonstrated that a high level of education makes the person more understanding and reacts to the events. They also found that the more social support the husband provided, the greater the anxiety and stress, implying that the high reliance on the husband and fear of losing him can increase anxiety and stress. In China, Shangguan et al. [21] found that chronic illness during or prior to pregnancy and current oral medication for chronic illness were reported by more women in the anxiety group than in the nonanxiety group but having neighbors or relatives with a diagnosis of COVID-19 was not associated with anxiety. Notably, the significant predictors in our study were primarily related to the uncertainty of pregnant women about health care facilities.

Another aim of our research was to assess participants’ perceptions of COVID-19 epidemiology and threats. According to the current study, approximately half of the participants believed that they were more susceptible to COVID-19 infection than nonpregnant and their antenatal clinic attendance represents an infection risk. Moreover, nearly two-thirds of the participants did not know if the virus transmitted vertically via the placenta and caused congenital anomalies to the fetus or not. Concerning these threats, the Royal College of Obstetrics and Gynaecology stated that pregnant women are no more or less susceptible to infection. Still, if they become infected, they are at risk of severe illness. Vertical transmission of COVID-19 infection is also uncommon, with no increased incidence of congenital anomalies [22].

A recent study on 178 pregnant women in Italy during the COVID-19 pandemic reported that 46.6% of them had anxiety due to their fear of potential fetal anomalies caused by COVID-19, 65% of them had a fear of intrauterine growth restriction, and 51% of them had fear of premature birth [23]. The results of Ahmed et al. [18] are in line with our study. Nearly all of their participants believed that the virus is transmitted vertically to the fetus, and pregnant women are more susceptible to infection, indicating a lack of awareness among Egyptian pregnant women toward COVID-19 infection.

The current study has some limitations: first, only pregnant women who had a cellphone with an internet connection were included in this study, and second, the lack of assessment of social predictors and their relation to the psychological status of pregnant women.

In conclusion, there was a high prevalence of anxiety, depression, and stress among the Egyptian pregnant women during the COVID-19 pandemic attributed to a variety of risk factors such as the limited income, low education, and previous history of COVID-19 infection of the participant or one of her family, in addition to the false concepts about the threats of COVID-19 infection.

Recommendations

  1. Raising the awareness of the population generally and the pregnant women, especially toward COVID-19 infection, is mandatory.
  2. Routine screening of all pregnant women for the psychological effect of COVID-19 pandemic should be done.
  3. Psychosocial support should be provided for pregnant women through hotlines or online counseling.
  4. Further studies are needed to assess other social variables and their relation to the psychological state and investigate the effect of any psychological disturbance on the maternal and neonatal outcomes.


Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflict of interest



 
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