Our study indicated that the risk of depression significantly increased among pregnant women after the pandemic. Our finding is consistent with a multi-centered study conducted in 10 Chinese provinces, which reported an increased depression risk in pregnant women after the outbreak of COVID-197. Several reasons could explain this situation. On the one hand, pregnant women may worry about COVID-19's effects on their health and offspring, increasing their risk of depression. Pregnant women would fear that the COVID-19 infection will likely affect placental function5,8 and seriously impact offspring, mainly abortion, premature birth, fetal embarrassment, low birth weight, fetal death, and neonatal death4,5. On the other hand, the COVID-19 control measures seriously impact pregnant women's daily life and routine antenatal examination, exposing them to the stress of "the epidemic is around the corner," which further increases their risk of depression.
We found that the psychological status of pregnant women did not improve during the back-to-normal period. Several reasons would have led to this phenomenon. First, the epidemic has not completely subsided globally, leading to the concern that the pandemic may come back in Shanghai at any time. Even Shanghai and the whole of China had recovered from the pandemic. The international epidemic is intensifying, and a port city, Shanghai, continues to have imported cases, making pregnant women think that the pandemic is still there. Second, the prevention and control measures had not been erased during the back-to-normal period, which continues to impact the daily life of pregnant women. For example, reducing the amount of prenatal exercise can increase the risk of prenatal depression9. Thirdly, the future direction of the epidemic is uncertain, and the ending time of control measures is not determined, so neonatal protection will make mothers feel overwhelmed after delivery. Therefore, under the normalization of the epidemic prevention and control, we should actively pay more attention to pregnant women's psychological status to reduce the long-term impact on maternal psychology and recover from the pandemic.
The study also found that pregnant women in early pregnancy have an increased risk of depression. This finding is also consistent with a survey conducted in Shanxi, China10. This study reported that the incidence of depression in early pregnancy was about 47.3%, much higher than 34.0% in middle and late pregnancy. Early pregnancy is a critical period for fetal development. Pregnant women in early pregnancy experience intensive diet, behavioral activities, and health care changes, which cause psychological imbalance. Some pregnancies are accidental, and the feelings of powerlessness on living changes lead to a growth in depression.
Our study indicated that after the outbreak of COVID-19, 12.9% of the participants were in moderate and severe depression (PHQ-9≥10). This high moderate and severe depression rate is a risk signal, and providing health education timely and effectively could help pregnant women to cope with their challenges. Thus, prenatal clinics should offer tailored services to help pregnant women handle their adverse situations to improve their psychological status during pregnancy. At the same time, it is necessary to carry out psychological state evaluation among pregnant women and make intervention timely. CHCs can provide psychological therapists to pay more attention to mental health during the maternal period and carry out tertiary prevention according to "Consensus on maternal mental health management (2019)"11, compiled by the Psychosomatic Health Society of China Preventive Medicine Association, and Committee of Women Mental Health Care of China Maternal and Child Health Association.
Our study has several limitations. First, the sample size was limited in this study, and the participants were the pregnant women from Fenglin Community, which can not represent Shanghai as a central part. Second, the factors influencing the mental health status included in this study are not yet comprehensive, and many of the potential confounders were not taken into consideration. Third, although the psychological assessment scales (PHQ-9 and GAD-7) used in this study are internationally recommended, the self-reported scales can not be diagnostic basis because of subjective effects.
In conclusion, pregnant women have an increased risk of depression after the COVID-19 outbreak. After the epidemic situation was stable, the psychological status of pregnant women did not recover. Maternal health care institutions should pay close attention to the long-term impact on pregnant women's psychology under the COVID-19 epidemic situation, strengthen the promotion of mental health of pregnant women, monitor the psychological status of pregnant women, offer timely intervention and carry out an effective referral.