Background
On January 20, 2020, a new coronavirus epidemic with human-to-human transmission was officially declared by the Chinese government, which caused significant public panic in China. In light of the coronavirus disease 2019 outbreak, pregnant women may be particularly vulnerable and in special need for preventive mental health strategies. Thus far, no reports exist to investigate the mental health response of pregnant women to the coronavirus disease 2019 outbreak.
Objective
This study aimed to examine the impact of coronavirus disease 2019 outbreak on the prevalence of depressive and anxiety symptoms and the corresponding risk factors among pregnant women across China.
Study Design
A multicenter, cross-sectional study was initiated in early December 2019 to identify mental health concerns in pregnancy using the Edinburgh Postnatal Depression Scale. This study provided a unique opportunity to compare the mental status of pregnant women before and after the declaration of the coronavirus disease 2019 epidemic. A total of 4124 pregnant women during their third trimester from 25 hospitals in 10 provinces across China were examined in this cross-sectional study from January 1, 2020, to February 9, 2020. Of these women, 1285 were assessed after January 20, 2020, when the coronavirus epidemic was publicly declared and 2839 were assessed before this pivotal time point. The internationally recommended Edinburgh Postnatal Depression Scale was used to assess maternal depression and anxiety symptoms. Prevalence rates and risk factors were compared between the pre- and poststudy groups.
Results
Pregnant women assessed after the declaration of coronavirus disease 2019 epidemic had significantly higher rates of depressive symptoms (26.0% vs 29.6%, P =.02) than women assessed before the epidemic declaration. These women were also more likely to have thoughts of self-harm ( P =.005). The depressive rates were positively associated with the number of newly confirmed cases of coronavirus disease 2019 ( P =.003), suspected infections ( P =.004), and deaths per day ( P =.001). Pregnant women who were underweight before pregnancy, primiparous, younger than 35 years, employed full time, in middle income category, and had appropriate living space were at increased risk for developing depressive and anxiety symptoms during the outbreak.
Conclusion
Major life-threatening public health events such as the coronavirus disease 2019 outbreak may increase the risk for mental illness among pregnant women, including thoughts of self-harm. Strategies targeting maternal stress and isolation such as effective risk communication and the provision of psychological first aid may be particularly useful to prevent negative outcomes for women and their fetuses.
Introduction
Several clusters of individuals with pneumonia of unknown etiology in Wuhan, Hubei province, China, were reported to the Chinese health authorities starting from December 8, 2019. The pathogen was identified as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the World Health Organization declared the virus outbreak a public health emergency of international concern. At the beginning of the outbreak, much remained unknown except that it was transmitted by direct exposure at a local animal market. Information on person-to-person transmission of the coronavirus disease 2019 (COVID-19) was revealed by the government to the Chinese public on January 20, 2020 and that asymptomatic individuals were potential sources of infection. , The number of identified cases continued to increase as did the public panic and flow of misinformation.
Why was this study conducted?
A crisis such as the coronavirus disease 2019 outbreak is a major public health event that causes significant uncertainty and isolation. The negative impact may be even greater among pregnant women who have increased stress owing to concerns for their fetus.
Key findings
An increase in the prevalence of depressive and anxiety symptoms was found after the declaration of coronavirus disease 2019 human-to-human transmission. Pregnant women also reported having significantly more thoughts of self-harm. Women at increased risk for depression after the crisis declaration included those who were primiparous, younger than 35 years, underweight before pregnancy, employed full time, in middle income category, and had a per capita living area of ≥20 m 2 and decreased physical activity.
What does this add to what is known?
Major public health emergencies may increase the depression and anxiety levels in pregnant women.
To date, epidemiologic data on the mental health problems of the general population during the COVID-19 outbreak have not been available and how to best respond to challenges during the outbreak remains unknown. Those in quarantine often experience boredom, loneliness, and anger, in addition, the virus has been repeatedly described as a killer virus on social media, perpetuating a sense of danger and uncertainty among the public. In the early phase of the 2003 SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychotic symptoms, and even suicidality, were reported. , Mandatory contact tracing and 14-day quarantine, which form part of the public health responses to the COVID-19 outbreak, increased anxiety, feelings of isolation, and stigma. ,
One particularly vulnerable group during a viral outbreak may be pregnant women. Mental health disorders are a common cause of morbidity during pregnancy with approximately 12% of women experiencing depression and up to 22% experiencing high levels of anxiety in late pregnancy. , Pregnant women are more vulnerable to infections because of their naturally suppressed immune system and are generally considered at increased risk for severe complications. Moreover, pregnant women may be further vulnerable to anxiety due to increased concern about vertical transmission to their fetus. To date, the mental health response of pregnant women to the COVID-19 outbreak has not been investigated. This study aimed to examine the impact of the COVID-19 outbreak on the prevalence of depression and anxiety and the corresponding risk factors during pregnancy.
Materials and Methods
Study design and data collection
Human-to-human transmission of COVID-19 was first confirmed and reported by the Chinese government on January 20, 2020. In early December 2019 before the COVID-19 outbreak, our team initiated a multicenter cross-sectional study to identify mental health concerns in pregnancy using the Edinburgh Postnatal Depression Scale (EPDS). This study provided a unique opportunity to compare the mental status of pregnant women before and after the declaration of the COVID-19 epidemic. To examine the effect of a major public health emergency on the mental health of pregnant women, data from January 1, 2020, to February 9, 2020, were obtained from the Perinatal and Postpartum Depression Information Collection System we created. For this study, all participants were categorized into 2 groups based on whether human-to-human transmission of COVID-19 had been reported when the study questionnaire was completed (group 1, before the declaration of human-to-human transmission; group 2, after the declaration). Information of the number of suspected, confirmed, and death cases of COVID-19 in China were obtained after the declaration made on January 20, 2020. This study was registered to the Chinese Clinical Trial Registry (ChiCTR1900027020), and the ethical approval was obtained from the institutional review board of International Peace Maternity and Child Health Hospital (GKLW2019-11). Informed consent was obtained from all participants.
Participants
This cross-sectional study was performed in 25 public hospitals from 10 provinces across China, covering the East, the Middle, the Northwest, the Northeast, and the South. Pregnant women in their third trimester of pregnancy were invited to complete a study questionnaire by a trained research assistant during their regular obstetrical clinic visit. Questions pertained to sociodemographic characteristics, lifestyles, reproductive history, history of mental health problems, current depressive symptoms, marital and family support, and pregnancy complications (threatened abortion, gestational diabetes mellitus, hypertensive disorder, placenta previa, intrahepatic cholestasis of pregnancy, oligohydramnios, and intrauterine growth restriction).
Assessment criteria
Depressive symptoms were measured by EPDS, the most frequently used and internationally recommended screening measure for perinatal depression. , EPDS was used to evaluate feelings in the last 7 days with a recommended cutoff score of 10 or higher to detect possible depression during community-based screening. , In this study, a cutoff score of 10 or higher was used to analyze group differences in depression because this lower cutoff score is recommended for Asian population. In addition to depression, EPDS may be used to assess anxiety symptoms. The accumulative score from the items 3, 4, and 5 in EPDS (EPDS-3A) represents the anxiety dimension. ,
Statistical analysis
All analyses were conducted with R statistical software version 3.6.2 (packages rms, ggplot2, ggradar, nCOV2019, recharts ). All reported probability values were 2-tailed, and the criterion for significance was set at P =.05. Univariate statistics and distribution were assessed; continuous variables were presented as means and standard deviations or median and interquartile ranges (IQRs). Categorical variables were expressed as frequency and percentage. The crude prevalence of depressive symptoms was displayed from January 1, 2020, to February 9, 2020. The chi-square test was used for categorical variables. Mann-Whitney U tests were applied to continuous variables with a non-normal distribution. We investigated the association between the number of changes per day (confirmed COVID-19 cases, suspected cases, or death cases) and EPDS scores using ordinary least squares linear regression models. We also investigated the risk for depression (EPDS≥10) using logistic regression models. The analyses were adjusted for potential confounders such as age, body mass index (BMI), education levels, occupation, annual household income, parity, investigation site, family support, per capita living area, maternal only-child status, pregnancy complications, and exercise level. Ordinal logistic regression model was used for a response variable with each EPDS items and with explanatory factors. Further model assumptions were assessed by plotting model residuals and evaluating R 2 /sum of squared residuals.
We performed a subgroup analysis to investigate whether the increased risk for depressive symptoms was associated with the declaration of the COVID-19 epidemic using radar plot and attributable risk proportion and 95% confidence intervals (CIs). To further examine risk factors, we examined COVID-19–related factors, baseline variables, and pregnancy complications using logistic regression. The parameters included COVID-19 epidemic declaration, education levels, occupation, annual household income, family support, per capita living area, maternal only-child status, placenta previa, and exercise. We also considered investigation sites, history of diseases, use of assisted reproductive technology (ART), and twin pregnancy as potential confounders, but adjustment for these variables did not change the results and therefore were not include in the final models. We did not use imputing data analyses due to no missing data.
Results
Sample characteristics
A total of 4124 pregnant women were included in the analysis, 2839 of whom were investigated before January 21, 2020 (group 1). The distribution of demographic characteristics, including geographic region, was similar between the 2 study groups ( Table 1 ). Owing to the small proportion of women with a history of anxiety or depression (<1%), we did not exclude them in the following analyses.
| Characteristic | Group 1 (n=2839) | Group 2 (n=1285) a |
|---|---|---|
| Jan. 1–20 | Jan. 21 to Feb. 9 | |
| n (%) | n (%) | |
| Age, median (range) y | 30 (27–32) | 30 (27–32) |
| Age groups | ||
| <35 y | 2461 (86.7) | 1097 (85.4) |
| ≥35 y | 378 (13.3) | 188 (14.6) |
| BMI, median (range) (kg/m 2 ) | 20.7 (19.1–22.9) | 20.6 (19.0–22.7) |
| BMI groups | ||
| <18.5 | 468 (16.5) | 231 (18.0) |
| 18.5–23.9 | 1907 (67.2) | 851 (66.2) |
| ≥24 | 464 (16.3) | 203 (15.8) |
| Race | ||
| Han | 2750 (96.9) | 1240 (96.5) |
| Minorities | 89 (3.1) | 45 (3.5) |
| Education | ||
| Primary school or less | 271 (9.5) | 96 (7.5) |
| High school | 376 (13.2) | 165 (12.8) |
| College | 1822 (64.2) | 876 (68.2) |
| Professional or graduate | 370 (13.1) | 148 (11.5) |
| Annual household income | ||
| <$4000 | 101 (3.6) | 54 (4.2) |
| $4001–$10,000 | 408 (14.4) | 195 (15.2) |
| $10,001–$20,000 | 797 (28.0) | 357 (27.8) |
| $20,001–$40,000 | 909 (32.0) | 430 (33.4) |
| >$40,000 | 624 (22.0) | 249 (19.4) |
| Per capita living area, median (range) (m 2 ) | 48 (38–60) | 47 (39–60) |
| Occupation | ||
| Does not work | 531 (18.7) | 228 (17.7) |
| Full-time worker | 1776 (62.6) | 831 (64.7) |
| Part-time worker | 532 (18.7) | 226 (17.6) |
| Marital status | ||
| Married | 2799 (98.6) | 1271 (98.9) |
| Single | 33 (1.2) | 12 (0.9) |
| Divorced | 7 (0.2) | 2 (0.2) |
| Parity | ||
| Primiparous | 1875 (66.0) | 884 (68.8) |
| Multiparous | 964 (34.0) | 401 (31.2) |
| Current smoker | ||
| Yes | 16 (0.6) | 5 (0.4) |
| Current alcohol consumption | ||
| Yes | 41 (1.4) | 18 (1.4) |
| Pregnancy complications b | ||
| Yes | 1203 (42.4) | 548 (42.6) |
| ART | ||
| Yes | 184 (6.5) | 68 (5.3) |
| History of anxiety or depression c | ||
| Anxiety only | 10 (0.4) | 4 (0.3) |
| Depression only | 6 (0.2) | 3 (0.2) |
| Anxiety and depression | 3 (0.1) | 2 (0.2) |
| Confirmed COVID-19 cases in participating Chinese provinces d | ||
| <500 | 1471 (51.8) | 647 (50.4) |
| ≥500 | 1368 (48.2) | 638 (49.6) |
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