Interpretation:
Covid-19 firstly identified and became epidemic in China and has resulted in an ongoing pandemic.16,17 The increasing numbers of death tolls, caused global fear and panic. After the first case of Covid-19, detected in Turkey, Turkish government rapidly carried out interventions and restrictions to prevent the spread of the virüs.18 05 May, the date of the beginning of our study, Turkish ministry of health announced that, total coronavirus cases in Turkey was 129,491.19 Our study was conducted after the start of restrictions in Turkey when the psychological and behavioral changes of the subjects were fully settled. A similar situation had been shown in a study, conducted in 2003 SARS outbreak in Hong Kong; with the rising in the number of cases, the level of anxiety scores also increased. The anxiety scores were highest approximately 1 month after the first SARS case was announced. Women between the 30–49 ages and less educated were more concerned. Anxiety scores of those who perceived that they were more likely to contract or die due to SARS were significantly higher.20
Perinatal anxiety is quite common and deserves clinical attention. According to a meta analyze published in 2017, which included 102 studies with total of 221,974 women, the over all prevalence for any anxiety disorder was 15.2%.21 Antenatal anxiety was associated with increased risks for preterm birth, low birth weight, earlier gestational age, and being small for gestational age, smaller head circumference.9 Also developmental delay22, especially the development of brain structure and function disorders in children are associated with prenatal anxiety and depression.7,23-26 While we know widely about perinatal anxiety, there is a limited knowledge about psychological responses caused by a pandemic. A multi-center cross-sectional study was initiated in China to compare the mental status of pregnant women before and after the announcement of the Covid-19 epidemic. A total of 4124 pregnant women during their third trimester were examined in this cross-sectional study, using the Edinburgh Postnatal Depression Scale (EPDS). They found that, awareness of Covid-19 epidemic significantly increased the prevalence of depressive symptoms (EPDS≥10) (aRR=1.20, 95% CI: 1.04, 1.40, 245 P=0.01) and the risk of self-harm thoughts (aRR=2.85, 95% CI: 1.70, 8.85, P=0.005). A linear positive association was also noted between EPDS scores and the number of new infections confirmed daily.27Gillian A. Corbett, et al. questioned total of 71 patients in the second and third trimester of pregnancy. Half of the women who did not have anxiety before, worried about their health during the delay phase of outbreak. This anxiety was related to health of their older relatives’, other children they had and then their unborn baby. 28
The previous researches, compared pregnant womens’ anxiety levels with before and after pandemic, not with non pregnant women, our cohort showed that pregnant women are vulnerable and they feel fear deeper. Interaction with their relatives (mother, father, friends), provides psychological support, but the necessity of social distanding did not allow this. From Calgary, Canada, 92.9% of 1987 individuals reported feeling loneliness more than usual due to the Covid-19 pandemic. 56.6% of participants had clinically elevated anxiety and 37.0% elevated symptoms of depression. Most of the participants expressed worries about their own life and their unborn baby due to the possibilty of infection. Researchers recorded that depression and anxiety symptoms were reduced if participants could complete enough sleep time and had better social support.7
According to a preliminary study from Turkey, mean BDI (Back Depression Index) scores, and mean BAI (The Beck Anxiety Inventory) scores were greater in the pregnant women. They interpreted that, in the absence of psychosocial support, adverse perinatal outcomes could occur.29 However, Mirzadeh and Khedmat also highlighted the need for psychological support for pregnant women during this pandemic30, in our study 62% of participants reported that they get adequate support, but it did not make difference on their anxiety levels.
During the course of pregnancy, maternal anxiety varies, Haddad et al.31, Teixeira et al.32 and Bhagwanani et al.33 reported that STAI-S levels were increased in the first and third trimester. Other studies have reported that STAI-S scores elevated significantly in the third trimester.15,34 The anxiety level differences between trimesters were not evaluated in an outbreak period, we found that, there was no difference of STAI-S and STAI-T levels
between trimesters.
Wearing masks, gloves, and washing hands have became daily life necessities for protection from the virüs. These attitudes were experienced before, in 2003, during SARS outbreak, about 70% of women wore a mask all or most of the times, and 40% washed their hands much more frequently than before.35 Self isolation and ‘not leaving home’ is another reaction to Covid-19 pandemic in pregnant women.28 Furthermore, domestic transportation registrations and the intensity of Covid-19 patients in hospitals, caused the pregnant women to avoid going to their prenatal visits. It was reported former SARS outbreak, the rate of cancelling or postponement of antenatal visits were high and about half of the women decided delivering in hospitals with fewer SARS cases.35 The fear of going to hospital was obviously high in our study and half of pregnants stated that they cancelled or missed their prenatal visits. In the course of pandemic time, it is reported that, cancelling of appointments, difficulties in accessing health units, or going to physicians without a supporter caused poor quality of prenatal care.7