European Journal of Cardiovascular Medicine

Covid 19 emerged as global public health emergency and became a leading cause of outbreak for respiratory illness ranging from minor respiratory tract infection to severe acute respiratory distress syndrome leading to increased mortality rates among the general as well as the pregnant and postpartum population. Since pregnancy itself is a relatively immune compromised and postpartum being the pro –inflammatory state it was hypothesized that pregnant and postpartum women may be at higher risk¹ This COVID-19 virus had some direct as well as indirect effects in pregnancy such as complications for both the mother and the fetus; including premature delivery and impaired fetal growth, respiratory distress, fetal distress, coagulopathy accompanied by liver dysfunction and death of the mother.2 

Covid 19 positive pregnant and postpartum women are at higher risk of developing severe symptoms like respiratory infection, sepsis, coagulopathy, kidney failure further increasing the need for ICU admission. The infection acquired may cause an extensive immune reaction in the placenta, like villous hyperplasia, and mural hyperplasia. This in turn causes chorioangiosis, fetal thrombosis, chorioamnionitis, and chronic villitis causing an increased rate of unfavourable outcomes during pregnancy such as preterm labor and higher maternal morbidity³.

Apart from overall adverse health impact, this pandemic has created many serious pyschological impact like anxiety and depression. Prevalence of anxiety disorder during pregnancy, in developed and developing countries, are 10 and 25%, respectively⁴.Fear about themselves of catching infection,  their older relatives health, existing children, their unborn baby, the risk of virus’s possible vertical transmission to the fetus, all these can cause higher level of anxiety, depression which can affect the pregnancy, childbirth and postpartum stages. Being a vulnerable population, pregnant and postpartum women with such untreated psychological illness can cause pregnant women have intergenerational psychosocial issues, including poorer child behavioral, cognitive, and poor socioemotional developmental outcomes.

The covid 19 norms which includes avoiding social gatherings, self-isolating and staying at home, have an additive negative impact on their mental status⁵. Isolation causing concerns related to food supplies and appropriate antenatal care puts her at all the more anxiety. Also this pandemic has caused pregnant women not receiving appropriate antenatal visits due to fears regarding infection catched from hospitals leading to adverse pregnancy outcomes. The development of poor pregnancy outcome in turn leads these females to more anxiety and depression.

The magnitude of the impact of the coronavirus disease 2019 (COVID-19) pandemic on the mental health of pregnant and postpartum women remained unclear since the beginning of the pandemic. As a result various quality assessments of studies, random-effects meta-analysis, sensitivity analysis, and planned subgroup analysis have been performed in different regions of the world for the assessment of the mental health impact, which have come out with varying results. Also, as there is a paucity of Indian studies revealing the psychological impact of the covid19 pandemic on pregnant and postpartum women, this study was planned to assess severity of three major psychological outcomes that is Anxiety ,Depression and fear using three specialized scales i.e Generalized Anxiety Disorder 7-Item Scale – GAD-7, Hamilton depression score HAM-D and Fear of covid 19 scale6,7,8. Understanding of the outcome variables is necessary for any research work .First psychological variable i.e Anxiety is an emotion which is characterised by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events^9. Depression being another variable  is a mood disorder that causes a persistent feeling of sadness and loss of interest¹⁰. Lastly Fear was assessed which is a basic, intense emotion aroused by the detection of imminent threat, involving an immediate alarm reaction that mobilizes the organism by triggering a set of physiological changes¹¹.With the help of this questionnaire overall anxiety and behavioral impact on pregnant women has been researched on both covid and non-covid participants. It has therefore drawn attention and critical resources to reproductive women and child health for having access to safe birth, antenatal care and puerperium care.

This cross-sectional study was done for one year (2020-2021), in a tertiary care hospital of Northern India in the department of obstetrics and gynaecology in collaboration with the department of Psychiatry, King George Medical University, Lucknow). Ethical clearance was taken from ethical committee of university (ECR/262/Inst/UP/2013/RR-19, Ref code: IEC-104 th ECM IIB-Thesis P7). Sample size was calculated, based on the level of confidence (95%), Z-score, Margin of error (10%), and Standard deviation. The sample size (n) = Z2SD (1-SD)/ MOR2, assuming 0.05 level significance (Zα/2 =1.96), was 96 in each group (covid positive pregnant and post-partum women as cases and covid negative as control) A total of 192 pregnant and post -partum women visiting our hospital both indoor and outdoor patients, with normal psychological behavior i.e those without any prediagnosed psychiatric illness, conscious, oriented and mentally sound were included in the study. Patients not giving consent or with grave illness or psychological disorder or who visited hospital OPD for gynecological complaints were excluded from the study. Informed written consent was taken from all cases and controls registered for the study.

Participants fulfilling the inclusion/exclusion criteria were interviewed face to face for the survey. They were first asked about their demographic details which included their name, age, parity, associated risk factors, education, occupation, monthly income, domicile and then every patient was interviewed using three different validated questionnaire scales namely, GAD 7 SCALE, HAM –D SCALE, and FEAR OF COVID 19 SCALE for the assessment of anxiety, depression and fear respectively in both the groups.GAD -7 SCALE included seven items which were correlated with total score. The seven items assessed are (1) feeling nervous, anxious, or on edge; (2) being able to stop or control worrying; (3) worrying too much about different things; (4) trouble relaxing; (5) being restless; (6) becoming easily annoyed or irritable; and (7) feeling afraid as if something awful might happen.6

Second scale used the Hamilton Depression Rating Scale (HDRS), sometimes also abbreviated as HAM-D, is a multiple-item questionnaire designed for adults which was used to rate the severity of depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and somatic symptoms.7

Third variable that is fear was measured by FEAR OF COVID 19 SCALE (FCV-19S).It is a seven-item scale and has a stable unidimensional structure with robust psychometric properties. The participants were asked to indicate their level of agreement with the statements using a five-item Likert type scale. Answers included “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree,” and “strongly agree”. The minimum score possible for each question is 1, and the maximum is 5. A total score was calculated by adding up each item score (ranging from 7 to 35). The higher the score, the greater is the fear of covid -198 .

Responses were then calculated as scores as used in validated questionnaires. The data was expressed as mean and standard deviation (SD) or median, range and percentage as appropriate. All the categorical data was compared by using chi square test. Continuous variables in two groups were compared by t- test. The p-value <0.05 was considered as significant. The statistical analysis was done using SPSS 21.0 version (Chicago, Inc., USA) windows software.

In the present study, for both the groups range of age of patients was 21-40 yrs. Mean age was 27 years and also there was no difference in the mean age of patients in the two groups. In case group, out of total 96 women, 68 were antenatal in which 33 were primigravida and 35 were multigravida. 28 women were postpartum in case group. In control group, 81 women were antenatal, in which 44 were primigravida and 37 were multigravida and 15 were post-partum females. Majority of the study population were with period of gestation <37 weeks in both case and control group accounting to 46.8 % in case. Majority of the sample population in our study, were from rural community accounting to 64.58 %in case group and in control group majority were from urban community accounting to 62.5 %. Distribution of our study on the basis of literacy it was found that majority of study objects in covid positive group were of primary level education or illiterate while in control group majority were graduate or of intermediate level education. (Table 1).The current study had pregnant participants with risk factors like hypertensive disorders of pregnancy(16.11%), intra hepatic cholestasis of pregnancy(1.47%), antepartum haemorrhage(14.7%), gestational/type 2 DM(11.76%),  malpresentations(2.94%),preterm/premature rupture of membranes(4.41%), heart disease(2.91%),anemia(13.1%),breathlessness(30.88%) oligo/poly/ anhydraminos, intrauterine death of fetus, Rh-negative pregnancy, jaundice, thrombocytopenia, IVF conceived comprising 20.58% ,in case group. Similar risk factors existed in the control group as well.Postpartum women included  were with risk factors like anemia of varying grades(41.6%), h/o PPH(30.71%), abdominal distension(20.4%),surgical site infections(7.41%), covid related symptoms(breathlessness,fever,pneumonitis) covering 48% both in case and control group with no significant difference.

Table 1: Demographic distribution in both case and control groups

*=Significant (p<0.05)

Table 2: Comparison of anxiety in both the groups using GAD 7 scale:

*=Significant (p<0.05)

Table 3: Comparison of depression in both the groups using HAM-D scale:

*=Significant (p<0.05)

Table 4: Comparison of fear in both the groups using fear of Covid 19 scale

*=Significant (p<0.05)

Table 5: Distribution of woman according to, GAD 7 scale, HAM-D and fear of  Covid 19 scale in case and control group

*=Significant (p<0.001)

According to Generalised anxiety disorder -7 scale applied in the current study, there was statistically significant difference in occurrence of severe grade anxiety in case group as compared to control group as shown in table 2 and 5.

Hamilton –Depression rating scale revealed that distribution of depression was significantly more prevalent in case group than control group and difference was statistically significant (p<0.001) as shown in table 3 and 5.

For the assessment of fear, fear of COVID 19 scale was used, according to which the percentage distribution of severe fear was 79.17% in cases vs 16.67% in controls with a significant p value (<0.001) as described in table 4 and 5

Analyzing and summarizing the data obtained from the study, psychological impacts have been brought into light that the covid 19 pandemic has caused.

According to Generalised anxiety disorder -7 scale applied in present study, huge difference was found in prevalence of grades of anxiety between the two groups which may be, because, the majority of the patients included, were during the second wave of covid 19 pandemic (march 2021-july 2021) which was a period of havoc having very high infectivity, severity of disease and morbidity rate. It was found that there was no patient with zero anxiety score, even asymptomatic cases had minimal anxiety and had a score of 1-2. This was supported by the fact that huge number of cases occurred during the second wave with high infectivity rate for which dedicated covid 19 hospitals were made.So, anyone, who visited hospital even if covid negative had feeling of anxiety, depression and fear and they opted for home isolation for fear of catching infection or worsening of symptoms. Similar results were obtained in a study done by Urszula Nowacka et al14 which showed Covid 19 infected pregnant women had twice more moderate and severe anxiety score when compared with the no covid group.A study done by Davenport MH et al 20 assessed the impact of covid 19 pandemic on the psychological status and found higher State Trait Anxiety Inventory scores during the pandemic times. Another meta-analysis of a subgroup of 13 studies done by Fan et al18 on anxiety of pregnant women during covid 19 pandemic found an overall anxiety prevalence of 42%. Another study done by Anna Stepowicz et al12 on total 210 patients in Poland at Department of Perinatology and Gynecology, Polish Mother’s Memorial Hospital and Research Institute which is a tertiary care unit, using STAI-state subscale, showed that anxiety levels in pregnant and post-partum women during the COVID-19 pandemic were significantly higher (STEN7, mean: 45 points).Saccone et al19 came up with similar results in his research study on a group of 100 pregnant women in Italy, with a significantly elevated mean STAI score of 45 points. Supporting the findings of our study by the conclusions of Mappa’s study, suggested a two -fold increase in the number of pregnant women who experience abnormal levels of stress and anxiety during the pandemic4.The Turkish author Ayaz et al20 evaluated the population of pregnant women prior and during the COVID-19 era concluded that depression and anxiety levels were significantly increased in the latter period. Anna Stepowicz et al12 included pregnant and postpartum women with positive history of mental treatment and applied PSS-10 scale which assessed the level of psychological distress and the perception of current situation as overloading and uncontrollable showing that those patients were more prone to feel stressed and overwhelmed. Present study findings are consistent with another study by Berthelot et al21, which also showed that previous psychiatric diagnosis, as well as low income could play an important role in the aggravation of anxiety symptoms.

Another scale that was applied in present study was Hamilton –Depression rating scale to assess depression, it was found that 35.42% in case and 0% in control had significantly severe grade depression in case as compared to control. This is in line with a study done by Fallon V et al22proving that COVID-19 study group had significantly higher mean EPDS scores compared with the control group. A cross-sectional study conducted on 403 pregnant women by Sut et al16 using a web-based survey to assess anxiety, depression in pregnant women during the COVID-19 pandemic found that prevalence of anxiety and depression in pregnant women significantly increased after the spread of COVID-19 infection supporting our findings of the study. Yan H et al23on a metanalysis also found that the prevalence rates of mental disorders among pregnant and postpartum women during the COVID-19 pandemic were high which is similar to the results obtained in present study. Sarah E.D. Perzow et al5 did a survey using the EPDS and STAI-short form during early pregnancy, prior to COVID-19, and during COVID-19 and found that depressive symptoms were higher during COVID-19 compared to pre-COVID-19 and just as high as during early pregnancy.

For the assessment of fear, newly developed FEAR OF COVID 19 scale was used in present study, according to which 79.17% in case group and 16.67% in control group had severe fear, signifying that cases had significantly more fear of Covid 19 as compared to control. The severity of fear was so high in case group that 65% of cases agreed that they have fear of losing life because of covid 19 out of which 27% strongly agreed for this fear. Khamees et al 24 also found that 77.5% of women of their study realized that pandemic would be a threat to their health. In study by Cigaran et al 25 only 45% of pregnant women showed fear related to the possibility that the pregnancy would be affected by the coronavirus infection. Similar to present study results, Fan et al 26 reported a prevalence of fear of childbirth as high as present study. In their study 67.8%, i.e., more than half of the pregnant women had fear of childbirth during the pandemic and they felt nervous when they thought about it. Focussing on the demographic details of the study done, it was found that mean age of affection of Covid 19 in pregnancy and post- partum women was 27 years in present study which was quite similar in other Indian study like Bachani et al13 in which it was 26.86 years. These results emphasized, that even younger age females were more prone for developing covid 19 infection. In a prospective cross – sectional study done in Warsaw, Poland to assess the anxiety level during the COVID-19 pandemic between COVID-infected and non-infected pregnant groups by Urszula Nowacka et al14 age range was 19.8- 45.5, mean age being 33.3 yrs. The above-mentioned studies showed comparatively higher mean age of patients in developed countries than in developing countries which is probably because, overall pregnancy occurred at lesser age in developing countries than in developed countries. Maximum females were from third trimester but even without having labor pains, they required admission due to presence of high- risk factors associated with pregnancy. Similar results were shown in other studies explaining maximum affection in third trimester of pregnancy.15 Present study also elaborated that the cases (covid positive) were more from illiterate, low income group and rural population as compared to control group (covid negative) who were from urban population. This is because this group had lack of knowledge about covid 19 infection, protocols, quarantine methods and hygiene which made them prone to covid 19 infection. Urban population on the other hand, had resources, supplies and knowledge through videos, television, social media which made them aware of the effects and so were less infected. Supporting this, a study done in Turkey by Sut et al 16 found that not only education helps in prevention of covid 19 incidence, it also helped in lowering anxiety and stress levels.

The present study thus proves that overall anxiety, depression and fear was more prevalent in the covid positive as compared to covid negative pregnant and post -partum women and the difference was statistically significant. So, for prevention of long- term impacts of psychological issues appropriate care and support that is needed will be provided timely.

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