Evaluation of Mental Health Status of the Pregnant Women Working in Hospitals During Covid-19 Era

Mahboubeh Eslamzadeh Mashhad University of Medical Sciences Bita Najjari Mashhad University of Medical Sciences Maryam Emadzadeh Mashhad University of Medical Sciences Zhaleh Feyzi Mashhad University of Medical Sciences Farzaneh Modaresi Fasa University of Medical Science Sara Mirzaeian Mashhad University of Medical Sciences Aazam Sadat Heydari Yazdi (  heydariazm@gmail.com ) Mashhad University of Medical Sciences https://orcid.org/0000-0002-2222-1758

There is a large body of evidence that addressed the increased prevalence of psychiatric disorders and mental health issues such as dementia, perceived psychological stress, anxiety, and depression during the COVID-19 pandemic and similar outbreaks (2)(3)(4).
In a national-wide survey in China, it is reported that national lockdown measures triggered a wide variety of psychological problems, such as panic disorder, anxiety, and depression in normal people as well as those with the previous mental health problems (5,6).
In COVID-19 crisis, with the outrages hospitals overload and the shortage of facilities, healthcare workers experienced excessive workload, longer working hours, more night shifts, and perhaps physical or emotional violence (7)(8)(9). These catastrophic occupational stressors make them at most risk of getting various mental health issues, such as depression, anxiety, and sleep disorders (10,11).
Women comprise over 70% of the health care workface, and many of them, perhaps thousands, are pregnant at any given moment (12). Of note, many of these pregnant women are front-line health care workers in the COVID-19 era and are worried about the possible impacts of COVID-19 on their fetus (13). Although it is argued that pregnant women are not at an elevated risk for COVID-19 infections (14), pregnant health care workers seem to be at higher risk for anxiety, occupational stress, and depression. Besides, individuals with pre-existing mental issues, including bipolar disorder, substance use disorder, obsessivecompulsive disorder, depression, or anxiety, are more vulnerable to infection (5,6,15). Based on the reasons presented above, it is crucial to study on mental health issues among pregnant health care workers. Furthermore, there is a lack of studies that investigate the mental health status of pregnant health care workers in the COVID-19 pandemic. Therefore, we conducted an online survey among pregnant health care workers, who work in referral hospitals of Iran, to better understand their mental state in COVID-19 crisis. Additionally, we evaluate the correlation between mental health status and the level of COVID-19 related anxiety in pregnant healthcare workers, including physicians, nurses, clinical staff, and medical trainees.

Study Design and Population
This cross-sectional, observational study was carried out among 64 pregnant clinical residents, general physicians, nurses and other medical staff who worked in the tertiary referral hospitals in Iran, from August 2020 to December 2020 using an anonymous online survey available on Google Form platform. The study included the pregnant clinical personnel who were willing to ll the online survey completely and working at hospitals at the time of study. We exclude individuals with prior history of psychiatric disorders or those who used psychiatric medications. Pregnant clinical personnel recruited via social media professional groups/pages, including Telegram, WhatsApp, and Instagram. The survey link was also shared with speci c medical communities to reshare through their networks of pregnant physicians.
This study was approved by the ethics committee of the Mashhad University of Medical Sciences (Ethics code: IR.MUMS.REC.1399.208). Each participant was free to decline to participate in this study with no consideration.

Data Collection
The online survey comprised of three sections: the rst section consisted of sociodemographic questions, occupational questions, pregnancy-related questions, and questions about medical/drug history, the second section included the Persian version of General Health Questionnaire -28 (GHQ-28), and the third section contained Corona Disease Anxiety Scale (CDAS).
We used Persian version of GHQ-28 in the current study (17). Which its validity, and reliability were assessed by Nazi et al. (17) and Cronbach's alpha was 0.923.

Corona disease anxiety scale (CDAS)
Corona disease anxiety scale was used to evaluate corona-related anxiety in two domains, including psychological symptoms and physical symptoms, on a 4-point Likert scale from zero to 3 (never: 0, sometimes: 1, often: 2 and always: 3). The total score ranges between 0 and 54. We used Persian translated version of this questionnaire, with the reported Cronbach's alpha of 0.919 (18).

Sample Size and Statistical Analyses
According to the study conducted by Judy Ng et al. in 2013 (19), which about 65% of pregnant women reported the moderate level of anxiety during SARS pandemic, the minimum sample size was calculated as 52 (considering p=0.65, d=0.2p and α = 0.05).
All statistical analyses were performed using the SPSS for Windows, version 22 software package (SPSS Inc., Chicago, IL, USA).
Kolmogorov-Smirnov test was used to assess for normality of the quantitative variables. Data were expressed as means (SD) for parameters with a normal distribution or median (interquartile range) for non-normally distributed data.
A two-sided P value <0.05 was considered statistically signi cant. Bivariate correlations between different parameters and GHQ-28 and CDAS score were performed using Pearson or Spearman's correlation test.

Demographics and Pregnancy-related Characteristics
This study included 64 pregnant health care workers with the mean age of 31.3 ± 3.9 years. The demographic and clinical characteristics were summarized in Table 1. The majority of subjects had <5 years work experiences (65.6%, n: 42). About onethird of pregnant health care workers (n: 22) have thought about abandoning their profession within the past month of the study ( Table 1).
The mean of gestational age of the participants was 24.5 ± 10.1 weeks. Table 2 illustrates that more than half of participants experienced their rst pregnancy (57.8%, n:37). Eleven subjects reported having one or more prior abortions (17.2%). Similarly, the frequency of unintended current pregnancy was 11 (17.2%) among pregnant health care workers ( Table 2).

Correlation between Mental Health Status and COVID-19 Related Anxiety with other Demographic, and Pregnancy-related Characteristics
The mean score of GHQ-28 was 26.8 ± 9.3 and the median (Q1-Q3) of CDAS total score was 10.0 (6.0-16.7) ( Table 3).
Pearson's correlation test showed that COVID-19 related anxiety and its subclasses, physical and psychological, were signi cantly correlated with GHQ-28 total score and its subclasses, including somatic symptoms, anxiety/insomnia, social dysfunction, and depression among pregnant health care workers (P<0.01, Table 4). However, neither psychological distress (assessed by GHQ-28) nor COVID-19 related anxiety were correlated with demographic and pregnancy related characteristics (Table 4).    *Data were expressed as mean ± SD for normally distributed parameters or median (Q1-Q3) for non-normally distributed parameters.

Discussion
In this study, we sought to better understand the mental health issues and the COVID-19 related anxiety in pregnant health care workers in Iran. Besides, we assessed the correlation between mental health status using the GHQ-28 score and COVID-19 related anxiety. As we found, the prevalence of moderate to severe psychological problems and COVID-19 related anxiety among pregnant health care workers were 9.4% and 26.5%, respectively. In addition, our results showed a signi cant correlation between COVID-19 related anxiety and its subclasses, physical and psychological, and GHQ-28 total score and its subclasses, including somatic symptoms, anxiety/insomnia, social dysfunction, and depression. Women comprise the majority of health care workers.
Therefore, the high prevalence of mental health issues (both occupational and non-occupational) among health care workers and pregnant women would necessitate conducting a study about mental health issues of pregnant health care workers.
Pregnancy is known to be a phenomenon with various physiological and psychological changes, such as immune system alterations (20). Pregnant women are vulnerable to stress and mental health issues since they have many concerns about the effects of COVID-19 on their pregnancy and labor (14,21). Although it is unclear whether pregnant women are at higher risk of developing severe COVID-19 and its complications, some studies suggested the probability of vertical transmission of COVID-19 to the fetus (22). In addition, some measures have been implemented that may increase the level of anxiety and psychological stress in pregnant women, including social distancing, minimizing in-person care, prohibiting labor partners for a time, and restricting visitors in postpartum wards (23)(24)(25).
According to the guidelines of several western countries, the employer is not allowed to continue employing a pregnant woman Sut et al. (30) reported that the prevalence of anxiety and depression was 64.5% and 56.3%, among pregnant women during the COVID-19.
Liu et al showed that health care workers who had close physical contact with COVID-19 patients were more anxious and depressed compared with their counterparts who had no contact. Close contact with COVID-19 patients was also shown to negatively affect the medical staff's quality of life (31). In contrast, a recent study reported that there was higher prevalence of anxiety among non-medical healthcare workers without direct contact compared to medical personnel who might have direct contact with COVID-19 cases (32). It has been reported that the social support of health care workers was associated with selfe cacy and quality of sleep. However, it had an association with decreased levels of stress and anxiety (33). In the current study, COVID-19 related anxiety and its subclasses, physical and psychological, were signi cantly correlated with GHQ-28 total score and its subclasses, including somatic symptoms, anxiety/insomnia, social dysfunction, and depression among pregnant health care workers.
The present study has several limitations. One of the limitations is its cross-sectional design. The investigation of causal relationships is impossible with a cross-sectional design. Another limitation is that participation in the study was voluntary; thus, there was the possibility of selection bias. In addition, the in-person questionnaires seem to be more accurate and reliable than the on-line questionnaires. However, in order to minimize the physical contact, we selected the on-line questionnaires. This manuscript doesn't contain any individual person's data.
Availability of data and materials: The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Competing interests:
There is no con ict of interest. Funding: Mashhad University of Medical Sciences, Mashhad, Iran Authors' contributions: MEs and ZF proposed and designed this research. MEm analyzed and interpreted the patient data. ASHY and BN were two major contributors in writing the manuscript. MEs, FM, SM cooperated in referring patients. All authors read and approved the nal manuscript and substantively revised it.