|Year : 2020 | Volume
| Issue : 3 | Page : 113-117
Psychological status of pregnant women during COVID-19 pandemic: A cross-sectional study from Mumbai
Shradha Khatri1, Aparna K Murthy2, Uzma Hashim1, Seby Kuruthukulangara1, Ashalass Kumari2, Prasad R Lele2
1 Department of Psychiatry, INHS Asvini, Mumbai, Maharashtra, India
2 Department of OBG, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||22-Aug-2020|
|Date of Decision||02-Sep-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||31-Oct-2020|
Col (Dr) Seby Kuruthukulangara
Department of Psychiatry, INHS Asvini, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: The ongoing COVID-19 pandemic poses important challenges to mental health. Pregnant women are a vulnerable group to experience adverse psychological impact of the pandemic, with consequences on maternal and foetal outcomes; currently there are scant data for the same in India. To the best of our knowledge, this report is the first from India on psychological status of pregnant women during COVID-19 pandemic. Aim: The aim is to study the impact of ongoing COVID-19 pandemic on psychological status of pregnant women. Setting and Design: Cross-sectional observational study in a tertiary care hospital setting in Mumbai. Materials and Methods: Out of total 98 pregnant women reporting to antenatal clinic of the hospital during the study period from June to July 2020, 66 gave informed consent to participate in the study. Perceived Stress Scale (PSS-10), Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) were administered using an online form. Statistical Analysis: Group comparisons were analyzed using appropriate nonparametric tests. Results: About 66.7% of women were primigravida, 39% in second trimester and 75.8% in age group 21–30 years. 28.8% missed scheduled antenatal visit, higher when compared to hospital data prior to pandemic. 39.4% worried about their unborn baby getting infected from Corona virus and 25.8% worried about themselves getting infected. About 72.2% reported moderate levels of perceived stress as measured by PSS-10, 51.6% reported mild-to-moderate level of depressive symptoms by PHQ-9 and 39.4% reported mild-to-moderate anxiety symptoms by GAD-7. PHQ-9 and GAD-7 scores of women aged 21–30 years were higher than those aged 31–40 years (P = 0.017 and 0.005 respectively). Conclusion: High rates of perceived stress, depressive, and anxiety symptoms in pregnant women found in this study suggest a need to incorporate psychological screening and interventions in routine antenatal care during ongoing pandemic.
Keywords: Anxiety, COVID-19, depression, perceived stress, pregnant women, psychological status
|How to cite this article:|
Khatri S, Murthy AK, Hashim U, Kuruthukulangara S, Kumari A, Lele PR. Psychological status of pregnant women during COVID-19 pandemic: A cross-sectional study from Mumbai. J Mar Med Soc 2020;22, Suppl S1:113-7
|How to cite this URL:|
Khatri S, Murthy AK, Hashim U, Kuruthukulangara S, Kumari A, Lele PR. Psychological status of pregnant women during COVID-19 pandemic: A cross-sectional study from Mumbai. J Mar Med Soc [serial online] 2020 [cited 2020 Nov 27];22, Suppl S1:113-7. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/3/113/299709
| Introduction|| |
In December 2019, an outbreak of novel Coronavirus pneumonia was reported in Wuhan City, China, which spread throughout the world and was eventually declared a pandemic by the World Health Organization in March 2020. The ongoing COVID-19 pandemic poses important challenges to public health, including mental health; for example, a survey conducted in China reported that more than half of the respondents (53.8%) from general population rated the psychological impact of the outbreak as moderate or severe.
There have been several reports published recently on COVID-19 and maternal physical health and obstetrical outcomes,, but only very few studies have reported on mental health of pregnant women during the ongoing pandemic. During pregnancy, expectant mothers often experience stress and anxiety about potential adverse obstetrical outcomes such as fetal abnormalities or foetal deaths. These anxieties and worries are likely to increase during infectious disease outbreaks such as current COVID-9 pandemic as reported recently. For example, more than half of the respondent pregnant women in a recent Italian study rated the psychological impact of COVID-19 pandemic as severe; more than two-thirds of pregnant women reported anxiety symptoms. Although India is one of the worst affected countries from COVID-19 pandemic, with a large population of pregnant women at risk, currently there are scant data from India on the psychological impact of ongoing pandemic in expectant mothers. To the best of our knowledge, our study is the first from India to report the psychological impact of the COVID 19 pandemic on pregnant women.
| Materials and Methods|| |
The study was cross-sectional and observational, conducted in a tertiary care hospital setting in Mumbai. The study population included all pregnant women attending the antenatal clinic of the hospital during the months of June and July 2020, and who gave informed consent to participate. Those who had a past history of psychiatric illnesses were excluded.
The psychological status of participants was assessed using the following instruments which have been used in previous Indian studies:
- Perceived Stress Scale (PSS-10) is a 10-item self-administered instrument to measure the degree to which situations in one's life are appraised as stressful 
- Patient Health Questionnaire (PHQ-9) is a 9-question self-administered instrument which is widely used to grade the severity of depressive symptoms 
- Generalized Anxiety Disorder questionnaire (GAD-7) is a 7-item, self-administered questionnaire which is used to assess the severity of anxiety symptoms 
For a minority of respondents who did not understand English, one of the authors manually administered Hindi version of the questionnaires.
Sociodemographic, ante-natal and psychological assessment data were collected through an online form from the participants. All participants were given the option of mentioning their contact phone numbers so that appropriate intervention comprising of counseling, pharmacotherapy or both could be offered to those found to have high psychological distress. Pregnant women who had high psychological distress were accordingly offered appropriate interventions, and their husbands and the treating obstetric team were informed about the same. The study protocol was approved by the institutional ethics committee of the hospital. Data were analyzed using GNU PSPP statistical analysis software version 1.2.0. Value of P ≤ 0.05 was taken as significant, and wherever feasible, two-tailed P value was taken.
| Results|| |
During the months of June and July 2020, a total of 98 pregnant women reported to the antenatal clinic of the hospital for antenatal care. One had a past history of psychiatric illness and was not included. Out of the rest 97 pregnant women, 66 (68.04%) gave informed consent for participating in the study.
The largest number of participants were in their second trimester (39.4%, n = 26) and belonging to the age group 21–30 years (75.8%, n = 50) [Table 1]. Majority were primigravida women (66.7%, n = 44). Assisted conception was the mode of conception in a small proportion (12.1%, n = 08). 10.6% (n = 7) preferred cesarean section rather than vaginal delivery. 28.8% (n = 19) of the responders had missed at least one scheduled antenatal visit during the pandemic. 39.4% (n = 26) answered “much” or “very much” worried about their unborn baby getting infected from the Corona virus; a relatively smaller number of them worried about themselves getting infected (25.8%, n = 17).
Among 66 pregnant women participants, 25.8% (n = 17) had history of medical comorbidities before conception, most common being hypothyroidism (n = 6) and diabetes mellitus (n = 4). Other lesser common medical co-morbidities included seizure disorder, anemia, PCOD, CVD, and pulmonary tuberculosis. During the course of pregnancy, 34.8% women (n = 23) developed new medical conditions such as gestational diabetes mellitus (n = 09), hypothyroidism (n = 07), deranged liver function tests (n = 03), complete heart block, low lying placenta, oligohydramnios, and cervical cancer (one each).
72.2% (n = 48) of pregnant women reported moderate levels of perceived stress, as measured by PSS-10 [Table 2]. Mean, median, and mode of PSS scores of the sample was 15.87 (+5.63), 16 and 14, respectively. 51.6% (n = 34) of pregnant women reported mild-to-moderate level of depressive symptoms as measured by PHQ-9. Mean, median, and mode of PHQ-9 scores of the sample was 6.46 (+5.28), 6 and 1, respectively. Majority (56.1%, n = 37) reported minimal anxiety symptoms, whereas 39.4% (n = 26) reported mild to moderate levels of anxiety symptoms as measured by GAD-7. Mean, median, and mode of GAD-7 scores of the sample were 4.95 (+4.81), 3 and 0, respectively.
Instrument scores and variables
No statistically significant differences were noted in scores of these 3 instruments when compared between groups of primigravida and multigravida, between different periods of gestation, between mode of conception (spontaneous versus assisted), between preferred mode of delivery (vaginal versus cesarean section), and between those who missed and not missed scheduled antenatal visits [Table 3].
Worry about getting infected (self and unborn baby) and variables
39.4% (n = 26) worried “much” or “very much” about their unborn baby getting infected from Corona virus, whereas 25.8% (n = 17) worried about themselves getting infected [Table 4].
|Table 4: Worry about getting infected (self and unborn baby) and variables|
Click here to view
| Discussion|| |
India has been one of the worst affected countries from the ongoing COVID-19 pandemic, with Mumbai being among the worst affected cities in India during the study period of June to July 2020. Although the widespread impact due to the pandemic on public health has been adequately recognized in India, there are currently scarce data on its impact on maternal mental health, which prompted this study.
Among the 66 pregnant women respondents in our study, 28.8% (n = 19) had missed at least one scheduled antenatal visit during the pandemic [Table 1], which is a higher percentage when compared to data of the hospital antenatal clinic before the pandemic (12.4%) (unpublished data). This could be due to worries ranging from self/unborn baby potentially getting infected from Corona virus from visit to the hospital, or due to unintended consequences of public measures against infection spread such as enforced lockdown for extended periods leading to overall reduction in movement of people, including routine hospital visits such as ante-natal care (ANC) visits. Similar to our study finding, a recent study from China reported that 41.9% of pregnant women in Wuhan (the epicenter of the pandemic in China) and 27.7% in Chongqing refusing to go for their scheduled ANC visits during the pandemic. 10.6% (n = 7) in our study preferred cesarean section rather than vaginal delivery [Table 1], which was slightly higher when compared to previous data of the hospital (<8%) (unpublished data). A similar slight rise in preference for cesarean section has been reported from China during the current pandemic (12.8% in Wuhan and 8% in Chongqing).
Majority (72.2%, n = 48) of pregnant women who participated in this study reported moderate levels of perceived stress [Table 2]. Similar findings of significantly higher distress among pregnant women have been reported when compared to nonpregnant women in Iran,, and when compared to pre-COVID pregnant women in Canada.
In this study, 51.6% (n = 34) of pregnant women reported mild-to-moderate levels of depressive symptoms [Table 2], whereas the prevalence of peripartum depression reported previously among Indian women was 14.6%. Similar higher depressive symptoms in pregnant women have been reported from Belgium (44.2%) but a relatively lower rate from Sri Lanka (19.5%). Compared to nonpregnant women, depressive symptoms were significantly higher in pregnant women in studies from Iran  and China. When compared with a cohort of pregnant women assessed before pandemic in Canada, the cohort of pregnant women assessed during pandemic had significantly higher depressive symptoms.
39.4% (n = 26) of pregnant women reported mild to moderate levels of anxiety symptoms, whereas the majority (56.1%, n = 37) reported only minimal anxiety symptoms [Table 2]. Previous studies had reported anxiety symptoms in 68% in Italy, 24.5% in Wuhan and 10.4% in Chongqing of China, 17.5% in Sri Lanka  and moderate-to-severe anxiety symptoms in 13.6% pregnant women surveyed in Belgium. Significantly higher anxiety symptoms than controls were also reported from Iran  and Canada. When compared with a cohort of pregnant women assessed before pandemic, cohort of pregnant women assessed during the pandemic had significantly higher anxiety symptoms.
Scores of PSS-10, PHQ-9 and GAD-7 of women in age group 21–30 years were higher than of women in the age group of 31–40 years. The difference in scores of PHQ-9 and GAD-7 between these two age groups were statistically significant (P < 0.05) [Table 3]. There was only one woman in the age group <20 years and hence was not compared in the above analysis. This finding of higher depressive and anxiety symptoms in the younger age group was like that from previous studies. For example, a study from China reported significantly poor psychological health in pregnant women aged 18–30 years compared to those from >30 years. Similarly, a Sri Lankan study reported significantly higher rates of anxiety and depressive symptoms in the younger age group (18–25 years).
There were no statistically significant differences in perceived stress, depressive and anxiety symptoms, when groups of pregnant women were compared based ongravida, period of gestation, mode of conception (spontaneous versus assisted), preferred mode of delivery (vaginal versus caesarean section) and missing/not missing scheduled antenatal visits. No significant differences in psychological status were noted with gravida status and mode of conception in a Chinese study. Although our study did not find a significant difference in rates of psychological symptoms among women with different trimesters, a Chinese study  and another study from Italy  reported poor psychological health in the first trimester compared to other trimesters. In contrast, a study from Iran reported highest anxiety symptoms in third trimester.
39.4% (n = 26) answered “much” or “very much” worried about their unborn baby getting infected from Coronavirus; interestingly, relatively less number of them worried about themselves getting infected (25.8%, n = 17). A previous study from China has also reported similar worry of getting infected in 90% (Wuhan) and 18.6% (Chongqing) of pregnant women surveyed. There were no statistically significant differences in respect to having worry about self or unborn baby getting infected, when groups of pregnant women were compared based on age groups, gravida, different periods of gestation, mode of conception (spontaneous versus assisted), preferred mode of delivery (vaginal versus cesarean section), and those who missed and not missed scheduled antenatal visits.
Limitations and strengths
Our study had several limitations, including low sample size, absence of a control group for comparison, response rate being 68.04% and limitations related to the online mode of data collection. Furthermore, being cross-sectional and exploratory in nature, the study included consecutive pregnant women reporting to antenatal clinic for 2 months, without predetermined sample size estimation.
Despite these limitations, this first-ever report from India on psychological status in pregnant women during the COVID-19 pandemic highlights high rates of perceived stress, depressive and anxiety symptoms in them, making them vulnerable for poor outcomes related to maternal and fetal health. For example, our study finds that the prevailing psychological distress may potentially influence them adversely in their obstetric decisions such as missing antenatal clinic appointments or preference for cesarean section. These findings are similar to those which have been widely reported from other parts of the world and reviewed in the recent literature.,,
Future research recommendation
A large-scale longitudinal study on the psychological status of pregnant women during the ongoing pandemic in India, and its impact on obstetric decision-making and outcomes, is needed to replicate our study findings.
| Conclusion|| |
Our study findings suggest that there is an urgent public health need to focus on pregnant women as a special vulnerable group during the ongoing COVID-19 pandemic in India and to incorporate psychological screening and interventions into protocols for antenatal care during this pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Carlos WG, Dela Cruz CS, Cao B, Pasnick S, Jamil S. Novel Wuhan (2019-nCoV) coronavirus. Am J Respir Crit Care Med 2020;201:7-8.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al
. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.
Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? Acta Obstet Gynecol Scand 2020;99:439-42.
Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C. Pregnancy and COVID-19: A systematic review of maternal, obstetric and neonatal outcomes. J Matern Fetal Neonatal Med 2020;33:1-13. [doi: 10.1080/14767058.2020.1781809].
Thapa SB, Mainali A, Schwank SE, Acharya G. Maternal mental health in the time of the COVID-19 pandemic. Acta Obstet Gynecol Scand 2020;99:817-8.
Valsamakis G, Chrousos G, Mastorakos G. Stress, female reproduction and pregnancy. Psychoneuroendocrinology 2019;100:48-57.
Saccone G, Florio A, Aiello F, Venturella R, De Angelis MC, Locci M, et al
. Psychological impact of coronavirus disease 2019 in pregnant women. Am J Obstet Gynecol 2020;223:293-5.
Jungari S. Maternal mental health in India during COVID-19. Public Health 2020;185:97-8.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann 2002;32:509-15.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
GNU Project. GNU PSPP (Version 1,2,0.20) [Computer Software]. Free Software Foundation. Boston, MA.
Liu X, Chen M, Wang Y, Sun L, Zhang J, Shi Y, et al
. Prenatal anxiety and obstetric decisions among pregnant women in Wuhan and Chongqing during the COVID-19 outbreak: A cross-sectional study. BJOG 2020;127:1229-40.
Mirzaei N, Sadatmahalleh SJ, Khomami MB, Moini A, Kazemnejad A. Sexual function, mental health, and quality of life under strain of COVID-19 pandemic in Iranian pregnant and lactating women: A Cross-sectional Study. Research Square; 2020. Available from: https://doi.10.21203/rs.3.rs- 52895/v1
. [Last accessed on 2020 Augt 16].
Gharagozloo M, Sadatmahalleh SJ, Khomami MB, Moini A, Kazemnejad A. Mental health and marital satisfaction changes of pregnant and lactating women during the COVID-19 pandemic (IR.MODARES.REC.1399.004); 2020. Available from: https://doi. 10.21203/rs. 3.rs-49590/v1
. [Last accessed on 2020 Aug 16].
Berthelot N, Lemieux R, Garon-Bissonnette J, Drouin-Maziade C, Martel É, Maziade M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet Gynecol Scand 2020;99:848-55.
Sidhu GS, Sidhu TK, Kaur P, Lal D, Sangha NK. Evaluation of peripartum depression in females. Int J Appl Basic Med Res 2019;9:201-5.
Ceulemans M, Hompes T, Foulon V. Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic: A call for action. Int J Gynaecol Obstet 2020;151:146-7.
Patabendige M, Gamage MM, Weerasinghe M, Jayawardane A. Psychological impact of the COVID-19 pandemic among pregnant women in Sri Lanka. Int J Gynaecol Obstet 2020;151:150-3.
Chen S, Zhuang J, Chen Q, Tan X. Psychological investigation on pregnant women during the Outbreak of COVID-19. Research Square; 2020. Available from: https://doi. 10.21203/rs.3.rs-28455/v1
. [Last accessed on 2020 Augt 16].
Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not ok: COVID-19 and maternal mental health. Front Glob Womens Health 2020;1:1.
Saadati N, Afshavi P, Boostani H, Beheshtinasab M, AbediP, Maraghi E. Health anxiety of pregnant women and its related factors during the pandemic of corona virus. Research Square; 2020. Available from: https://doi. 10.21203/rs.3.rs-26840/v1
. [Last accessed on 2020 Aug 16].
Abdoli A, Falahi S, Kenarkoohi A, Shams M, Mir H, Jahromi MA. The COVID-19 pandemic, psychological stress during pregnancy, and risk of neurodevelopmental disorders in offspring: A neglected consequence. J Psychosom Obstet Gynaecol 2020;41:1-2.
Ali NA, Shahil Feroz A. Maternal mental health amidst the COVID-19 pandemic. Asian J Psychiatr 2020;54:102261.
Zeng LN, Chen LG, Yang CM, Zeng LP, Zhang LY, Peng TM. Mental health care for pregnant women in the COVID-19 outbreak is urgently needed. Women Birth 2020;S1871-5192:30210-9.
Spiniello L, Di Mascio D, Bianco C, Esposito O, Giangiordano I, Muzii L, et al
. All we know about COVID-19 in pregnancy: From perinatal to ethical and psychological perspective. The Official Publication of Perinatal Medicine Foundation. Turk Perinatol Soc Turk Soc Ultrasound Obstet Gynecol 2020;28:120-6.
[Table 1], [Table 2], [Table 3], [Table 4]