The current outbreak of the COVID-19 in Wuhan City and the other major cities (including Xiangyang) in Hubei province has raised global concerns. The COVID-19 pandemic, and associated quarantine measures, and hospital isolation, and social distancing to contain the virus, have contributed to increased anxiety symptoms and negative emotion among the general populations in China (26, 27). Pregnant women formally considered a vulnerable population, prone to develop anxiety and other adverse emotions, mainly because of their physical, psychological and social changes (28). This study is performed to identify anxiety symptoms and associated factors in pregnant women during the COVID-19 pandemic. In this representative sample of pregnant women living in Xiangyang, 31.64% of participants reported having anxiety symptoms. Prevalence of anxiety symptoms during pregnancy was associated with physical exercise and economic burden. As this was a cross-sectional retrospective study, these causal relationships could not be determined from this study.
The COVID-19 pandemic could yield a variety of negative psychological effects in different groups of the population, including pregnant women (5, 29, 30). Pregnant women are more likely to develop anxiety (5, 14), which is considerable depending on physical conditions and living environment (31). Since the COVID-19 was rapidly advancing in China with high mortality risk, Chinese government had implemented control measures including lockdowns, home quarantines and hospital isolation to slowing the COVID-19 transmission across China. Moreover, pregnant women were worried that they or their family members might contract COVID-19, and consequently, transmitting it to their foetuses (26). These factors mentioned above may contribute to the development and persistence of anxiety symptoms among pregnant women (30, 32). During the COVID-19 pandemic, the results of previous studies showed that pregnant women had higher prevalence of anxiety symptoms compared to the general population or the pregnant women before the COVID-19 outbreak, which is in line with the present study (4, 33–35). For example, a large cross-sectional survey showed that the prevalence of anxiety symptoms in workers during the epidemic period of the COVID-19 in China was 3.4% (36). Liu et al. found that 24.5% of pregnant women in Wuhan were suffering from anxiety symptoms during the COVID-19 outbreak (14). A study in Iran found that 43.9% of pregnant women had moderate-to-severe anxiety symptoms (35). A web-based cross-sectional study found that, in Colombia, the proportion of pregnant women with anxiety symptoms was as high as 50.4% (37). More recently, Zhu et al. carried out a cross-sectional study in Gansu Province (China), and it was observed that the pregnant women’s anxiety level was comparable to that of the front-line medical staff during the COVID-19 pandemic (38). Anxiety symptoms during pregnancy have repeatedly been demonstrated to be an independent risk factor for adverse obstetric and neonatal outcomes (22, 23). In this regard, pregnancy care providers (obstetrician-gynecologist, neonatologist and nurses) and other public health professionals should actively provide credible, useful and real-time information and emotional support to pregnant women exposed to a public health emergency, such as the COVID-19 pandemic. Moreover, acceptable and effective means of providing accurate and health care information related to the COVID-19 or other infections to the pregnant women are needed.
In the present study, we found that pregnant women with bank loans were at a higher risk for developing anxiety symptoms during the COVID-19 pandemic. This association was not confounded by monthly household income. It is worth to underline that the COVID-19 pandemic has affected the employment and family incomes (39). For instance, the normal economic activity was suspended during the COVID-19 pandemic, and the monthly household income has been temporarily reduced or suspended. For the pregnant women whose income was heavily affected by COVID-19, they may have difficulties in paying bills and loans (6). The burden of bank loans may contribute to pregnant women’s experiences of anxiety symptoms. Thus it is possible that pregnant women with bank loans or household debt during the COVID-19 pandemic were prone to experiencing mental symptoms of anxiety. Among pregnant women, those with lower incomes also report greater symptoms of anxiety and poorer birth outcomes (40, 41). Similarly, pregnancy women with low family income were at increased risk to develop anxiety symptoms during the COVID-19 pandemic (11, 14). For example, the results of Li et al. study showed that pregnant women with income losses the COVID-19 pandemic had higher prevalence of anxiety symptoms compared to unpregnant women (14). In our study, although there was not a significant association between the participants’ household income and their anxiety symptoms, we believe that household income during the COVID-19 pandemic may have a contribution to anxiety symptoms among pregnant women. In this respect, in order to improve birth outcomes and child development trajectories, it is recommended that the government and policy makers should develop and implement policies to provide financial support for low-income pregnant women and their families with bank loans during the pandemic.
In numerous studies, regular physical activity is reported to be a protective factor against anxiety symptoms in pregnant women (31). In this study, there was a significant relationship between participants’ daily walking activity with anxiety symptoms. We found that the participants with pedometer steps greater than 2000 steps/day and exercise frequency at least 4 time/week were less likely to anxiety symptoms. We speculated that the trimester-specific effect of regular walking activity on anxiety symptoms is mostly due to biochemical and neurophysiological changes over time. For example, Mild-to-moderate intensity exercise such as daily walking increases the release of neurotransmitters, such as serotonin (5-TH), dopamine, and noradrenaline, these neurotransmitters were found associated with a better response to anti-anxiety treatment (42). In a study conducted by Kahyaoglu et al.(10), it was shown that pregnant women who do not engage in regular physical activity have a higher risk of anxiety than pregnant women who engaged in regular physical activity during the COVID-19 pandemic. Hence, it is plausible that the practice of daily walking activity, being associated with a reduced probability of anxiety symptoms among pregnant women, could be a protective factor during the COVID-19 pandemic. Since the aerobic activity most commonly performed by women during pregnancy is walking, in clinical work, we hope that medical stuff encourage pregnant women to regularly participate in planning physical activity to benefit their mental health. For the pregnant women themselves, they should actively seek out care advice from healthcare professionals such as physicians and nurses, adhere to practical advice on lifestyle modifications, and find proper outlet for their motions to avoid anxiety symptoms and its negative consequences.
The results of this study provide new data on the association between physical exercise, economic burden and anxiety symptoms among pregnant women during the COVID-19 pandemic. However, several limitations of this study need to be acknowledged when interpreting the results. First, the data were collected in early March, when the number of new coronavirus cases continues to decline and the overall epidemic situation remains at a low level in China. Thus the results of the present study may not be able to be generalized to the more advanced phases of the pandemic. Second, it was conducted at a single center and our participants were not representative of the population of pregnant women in China. There is the possibility of selection bias. Third, with a cross-sectional study design and the use of self-reported data, no cause-effect relationship can thus be established in this study. Forth, the present study used the SAS to assess anxiety symptoms, thus the results of anxiety symptoms might lack comparability with clinical diagnostic measurements of anxiety. Finally, the data were collected online, thus preventing a face-to-face interview of the respondents. There is a chance that those who have anxiety disorders are not able to complete the questionnaire online, and hence respondent bias may be present. Despite these limitations, the present findings will convey evidence-based information to healthcare professionals when they provide comprehensive care to pregnant women.