Objective
The coronavirus disease 2019 (COVID-19) outbreak poses significant risk to public health, including mental health. A survey conducted in China showed that 53.8% of the respondents rated the psychological impact of the outbreak as moderate or severe, and 28.8% reported moderate to severe anxiety symptoms and stress levels. During pregnancy, women may experience stress and anxiety associated with potential adverse obstetrical outcomes such as fetal death or fetal abnormalities. Stress and anxiety level may also increase during infectious disease outbreaks. Currently, there is no known information on the psychological impact, the effect on individual’s social and/or psychological aspects, and mental health of pregnant women during the COVID-19 epidemic. This study aimed to survey pregnant women to evaluate psychological impact and anxiety during the COVID-19 outbreak.
Study Design
This was a cross-sectional survey study aimed to assess the psychological response of pregnant women during the COVID-19 epidemic. The study was conducted at the University of Naples Federico II (Napoli, Italy) from March 15, 2020, to April 1, 2020. Women with singleton pregnancies were eligible to participate in the study regardless of gestational age.
After a written informed consent was obtained from eligible participants, women were asked by their counselor to fill out 2 questionnaires. A combination of validated measures in the questionnaires was used to assess the psychological impact and anxiety.
Psychological impact questionnaire
The psychological impact of COVID-19 was measured using an Italian version of the Impact of Event Scale-Revised (IES-R). The IES-R is a 22-item self-administered questionnaire composed of 3 subscales aimed to measure the mean avoidance, intrusion, and hyperarousal. Each item can be scored from 0 to 4. Total score therefore can ranges from 0 to 88, with higher scores representing higher psychological impact. The total IES-R score was divided into 0–23 (normal), 24–32 (mild psychological impact), 33–36 (moderate psychological impact), and ≥37 (severe psychological impact).
Anxiety questionnaire
Anxiety of COVID-19 was measured by an Italian version of the 6-item short form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI), as described by Marteau and Bekker. Women can be scored on a scale of 20–80, with higher scores representing higher levels of anxiety. A STAI score of 34–36 was considered normal.
Women were also asked to fill out the visual analog scale (VAS) for anxiety. VAS for anxiety ranged from 0 (not at all anxious) to 100 (extremely anxious) and referred to the following question: How anxious are you regarding the coronavirus epidemic and the possibility of vertical transmission to your offspring?
To evaluate the anxiety of pregnant women during the COVID-19 outbreak, we also assessed the following:
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Rate of cell-free DNA compared with combined screening as first-trimester screening test (only in women who are enrolled in the first trimester of pregnancy)
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Mode of delivery and rate of cesarean delivery on maternal request (only in women who delivered during the study period)
Statistical analysis
Univariate comparisons of dichotomous data were performed using the chi-square test with continuity correction. Comparisons between groups to test group means with standard deviation were performed using t -test by assuming equal within-group variances or using one-way analysis of variance. A 2-sided P value less than .05 was considered statistically significant. Questionnaire scores were also analyzed according to the gestational age at patient’s enrollment.
Results
During the study period, a total 100 women were enrolled; 17, 35, and 48 women were in the first, second, and third trimester of pregnancies, respectively. None of the enrolled women had a history of postpartum depression in a prior pregnancy or of psychiatric disorders.
Overall, the COVID-19 outbreak had a moderate psychological impact on pregnant women with a mean IES-R score of 36.9±10.1. More than half of the respondents (53 of 100, 53%) rated the psychological impact as severe. Mean score at STAI questionnaire was 45.2±14.6, with an overall incidence of STAI >36 of 68% (68 of 100). Mean score at VAS for anxiety for COVID-19 vertical transmission was 43.0±26.9, with an overall incidence of score >50 of 46% (46 of 100) ( Table 1 ).
| Variables | n=100 |
|---|---|
| Psychological impact | |
| Mean IES-R | 36.9±10.1 |
| IES-R≥24 | 95 (95%) |
| IES-R≥33 | 61 (61%) |
| IES-R≥37 | 53 (53%) |
| Anxiety | |
| Mean STAI | 45.2±14.6 |
| STAI>36 | 68 (68) |
| Mean VAS-A | 43.0±26.9 |
| VAS-A≥50 | 46 (46) |
| First-trimester screening test a | |
| Women who opted for cell-free DNA | 9 (52.9) |
| Mode of delivery b | |
| Vaginal delivery | 10 (55.6) |
| Cesarean delivery | 8 (44.4) |
| Cesarean delivery on maternal request | 3 (16.7) |
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