Self-care Performance of Iranian Pregnant Women in Preventing COVID-19 Infection and Its Relationship With Perceived Stress

Background: The crisis of COVID-19 disease causes stress in the whole population, including pregnant women, and because pregnancy is a potentially stressful event, it can lead to complications in both mother and fetus. Considering the importance of prevention in controlling of this infection, the present study was conducted to determine the status of self-care performance of pregnant women in the prevention of COVID-19 disease and its relationship with perceived stress during the epidemic period of this disease. Method: This cross-sectional study was performed on 228 pregnant women who referred to Tabriz-Iran health centers for prenatal care by cluster sampling. Data collection tools included questionnaires of demographic-social characteristics, self-care performance and perceived stress. Spearman correlation test was used to examine the correlation between self-care performance and perceived stress in bivariate analysis and in multivariate analysis, multivariate linear regression with control of demographic-social and obstetric characteristics as possible confounders, was used. Results: The median (25-75 percentiles) self-care performance score of participants was 0.71 (0.65-0.76) from the achievable range of 20-80, and the mean (±SD) perceived stress score of them was 25.5 (± 5.6) from the achievable range of 0-56. The Spearman’s rank correlation test results showed a signi�cant inverse correlation between perceived stress and self-care performance scores. According to multivariate linear regression test, the variables of self-care performance, education, spouse's education and number of family members were the predictors of perceived stress in pregnant women during COVID-19 epidemic. Conclusion: According to the results of the present study, the self-care performance of pregnant women in the prevention of COVID-19 disease was good and their stress was moderate. There was a signi�cant inverse correlation between self-care performance and perceived stress, which could indicate the high value and importance of the fetus for the mother and strict adherence to health protocols to prevent COVID-19, which also leads to calming and reduced perceived stress.


Background
Coronavirus disease (COVID- 19) is an extremely infectious disease, which has been referred to as a "public health emergency" by the World Health Organization (1).The rst case of COVID-19 pneumonia was reported in Wuhan City, Hubei Province, China, in December 2019.The diagnosis of COVID-19 pneumonia is based on epidemiological exposure, clinical symptoms, laboratory tests, chest computed tomography (CT) results, and a positive COVID-19 test result based on quantitative reverse transcription-polymerase chain reaction (QRT-PCR) analysis of samples taken from the respiratory system (2).
Pregnancy is a physiological condition that predisposes women to viral infections.There are concerns about the potential effects of COVID-19 infection on fetal and neonatal outcomes, and pregnant women are considered a high-risk group that requires special attention (2).Due to physiological changes in the immune and cardiopulmonary systems of pregnant women, clinical manifestations of COVID-19 infection are likely be severe during pregnancy.In 2009, pregnant women constituted 1% of all in uenza A H1N1 cases, while they accounted for 5% of H1N1-related deaths (3).In addition, both the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV) were the cause of serious complications during pregnancy including the need for intubation, admission to intensive care units (ICUs), kidney failure, and death (4).Several cases of pregnancy loss (miscarriage or stillbirth) have been observed in women infected with SARS-CoV and MERS and high fever during the rst trimester of pregnancy can increase the risk of some birth defects (5,6).
Extensive research on this novel coronavirus can fully clarify its transmission routes and pathogenic mechanisms and specify potential drug targets.This would help authorities develop effective preventive and therapeutic measures.Considering the rapid increase in the number of COVID-19 patients, it is very important to diagnose and isolate all suspected cases as quickly as possible to control the source of infection (7).
Public health measures are needed to control COVID-19 infection, restrict its global outbreak, and reduce relevant damages.Lack of immunity to the novel coronavirus has predisposed a large number of people to infection, and the fast global spread of the virus has led to public panic worldwide.On the other hand, prenatal psychosocial stress is quite common among mothers, and high levels of stress lead to poor pregnancy outcomes(8).Epidemics, which are often widely publicized in the mass media, are associated with high levels of stress and anxiety (9).The COVID-19 crisis increases stress levels in the general population, and since pregnancy is a potentially stressful event, this infection can cause several maternal and neonatal complications (10).According to many epidemiological studies, psychosocial stress is associated with abortion, preeclampsia, preterm delivery, low birth weight, and congenital anomalies (11)(12)(13).Prenatal stress can also lead to other complications such as hypothalamic-pituitary-adrenal (HPA) axis dysfunction, depressive symptoms (in adolescence), and asthma (in childhood) (14).
Therefore, it seems necessary to control pregnant women's stress levels in various critical situations such as the COVID-19 pandemic.In general, an infection can be controlled through increasing public awareness, wearing protective clothes, using treatment measures, and, perhaps most importantly, vaccinating the general public.However, hospitalization, quarantine, and implementation of safety measures are critical to the containment of COVID-19 infection (15).In this regard, practical and emotional support from informal networks (families) and health professionals, clear and concise communication of necessary instructions, and simple daily physical exercises performed at home or in quarantine (to maintain mobility and reduce stress levels) can lower the increasing trend of COVID-19 infection worldwide(16).
On the other hand, self-care is the rst step to help mothers, better manage their illnesses, and the health slogan of 2014, "A lifetime of health with self-care", indicates the need to improve the self-care capabilities of all people(17).Self-care measures reduce various complications, hospital readmissions, and health costs and increase patients' satisfaction, and their sense of control over themselves, their disease, and various symptoms.Low levels of self-care are associated with poor health outcomes(18).Despite the widespread media coverage of COVID-19, there is still little information about the self-care performance of people, especially in highrisk groups such as pregnant women.Given the importance of this emerging disease and the necessity of communicating prevention and selfcare measures, especially to vulnerable groups, we decided to conduct the present study with the aim of determining the self-care performance of pregnant women in the prevention of COVID-19 and its relationship with their perceived stress.

Method Study design and participants
After obtaining permission from the Ethics Committee of Tabriz University of Medical Sciences (Code:IR.TBZMED.REC.1399.403),this crosssectional study was conducted on 228 pregnant women visiting the health centers of Tabriz, East Azerbaijan Province, Iran in 2020 for routine pregnancy care.The Inclusion criteria were having a le at a health center, having a telephone number to communicate with, and minimum educational attainment (i.e.reading and writing skills).The exclusion criteria also included the self-reported history of mental illness, high-risk pregnancy (e.g.suffering from heart diseases, hypertension, lung diseases, iron de ciency anemia, diabetes, thyroid disorders, and epilepsy) based on their medical records, and self-reported experience of a severe psychological crisis (e.g.death of a relative) in the past 3 months.

Sampling
The participants were selected using cluster sampling method.First, 22 health centers (a quarter of all health centers) in Tabriz were randomly selected, and the list and phone numbers of pregnant women covered by those centers were extracted from Iran's Integrated Health System (SIB).
Then, the participants were randomly selected from each center in proportion to the number of pregnant women covered by each center.The author then made phone calls to brief the participants on the research objectives and procedures and evaluate them in terms of the inclusion and exclusion criteria.Finally, the eligible candidates were asked to visit the respective health centers at a speci c time and complete the informed consent form and relevant questionnaires while observing necessary health protocols.

Data collection tools
The socio-demographic questionnaire included items about the participants' age, educational attainment, job, income level, number of children, etc.
Self-Care Performance Questionnaire (designed to prevent COVID-19 infection in pregnant women): This 20-item questionnaire was developed by the research team based on self-care instructions of the Iranian Health Education and Promotion Association (19).The items are scored based on a 4-point Likert scale from always to never.The total score on this questionnaire ranges between 20 and 80, and higher scores indicate better selfcare performance.Scores from "20-40", "41-60", and "61-80" indicate poor, moderate, and good self-care performance, respectively.

Cohen's Perceived Stress Scale
Cohen's 14-item Perceived Stress Scale (14-PSS) was developed in 1983 by Cohen et al.Three versions of this scale (including 4, 10, and 14-item scales) have been developed to measure general perceived stress level over the past month.The 14-PSS measures an individual's thoughts and feelings about stressful events and assesses his/her control over experienced stresses and tensions.This scale also examines risk factors associated with behavioral disorders and shows the process of stressful relationships.The items are scored based on a 5-point Likert scale anchored with 0 "never", 1 "almost never", 2 "sometimes", 3 "fairly often", and 4 "very often".Items 4, 5, 6, 7, 9, 10, and 13 are scored inversely, and range from never (score 4) to very often (score 0).The total score on this scale ranges between 0 and 56, and higher scores with a cut-off score of 21.8 indicate higher perceived stress levels (20).
Ten professors from Mashhad University of Medical Sciences con rmed the content validity of these measurement tools.Bastani et al. con rmed the reliability of the Persian version of 14-PSS by measuring its internal consistency (Cronbach's alpha = 0.74) (21).
The content validity of the self-care performance questionnaire was con rmed with a Content Validity Index (CVI) of 0.82 and a Content Validity Ratio (CVR) of 0.88.The test-retest reliability of 14-PSS and the self-care performance questionnaire was also con rmed with Intra-class Correlation Coe cients (ICCs) of 0.85 and 0.79 and a Cronbach's alpha of 0.95 and 0.85, respectively.

Sample size
The sample size was estimated at 138 in G-power ( =0.05, two-tailed; power = 95%; correlation coe cient = 0.3).Since the cluster sampling method was employed, the sample size was increased to 207 by considering a design effect of 1.5.Moreover, assuming an attrition rate of 10%, the nal sample size was determined to be 228.

Statistical analysis
The obtained data were analyzed in SPSS-21.The normality of the quantitative data was tested using the Kolmogorov-Smirnov test.The quantitative and qualitative variables were assessed using measures of central and dispersion indicators, and frequency (percent), respectively.In the bivariate correlation analysis, Spearman's rank correlation coe cient test was used to examine the correlation between self-care performance and perceived stress levels.Multivariate regression tests were also conducted by controlling the confounding effects of socio-demographics and midwifery variables.To this end, the independent t-test and one-way ANOVA were rst performed to determine the relationship of sociodemographic and midwifery variables with perceived stress.Then, the backward elimination strategy was used to insert variables that had a signi cant relationship with perceived stress (p < 0.05) and self-care performance into a multivariate linear regression model.

Results
The data were collected from August to September 2020 during the COVID-19 pandemic.The participants included 228 pregnant women, 17 of whom had a history of COVID-19 infection.The mean (± SD) age of the participants and their spouses was 25.7 (± 6.7) and 31.8 (± 5.5) years, respectively.The education level of most women (43%) was a diploma or higher and most of them (83%) were housewives.About half of the spouses had diploma and university education (54%) and 53% of them were self-employed.More than half of the women lived in private homes (56%), and most of them (85%) were satis ed with their married life.The mean (± SD) gestational age of the participants was 24.9 (± 9.1) weeks; about one-third of participants (35%) were primiparous, and only 9 of them (3.9%) had a history of infertility (Table 1).The mean (± SD) perceived stress score of participants was 25.5 (± 5.6) and the median (25-75 percentiles) self-care performance score of them was 0.71 (0.65-0.76).The Spearman's rank correlation test results showed a signi cant inverse correlation between perceived stress and selfcare performance scores (p = 0.041) (Table 2).In total, 85%, 13%, and 2 % of participants had a good, moderate, and poor self-care performance in preventing COVID-19 infection.The Kruskal-Wallis and Mann-Whitney U tests indicated that the type of pregnancy (i.e.wanted or unwanted pregnancy), spouse's educational attainment, housing status, and marital satisfaction had signi cant relationships with participants' self-care performance (p < 0.05).The t-test and one-way ANOVA results demonstrated that the perceived stress level had a signi cant relationship with women's educational attainment, spouse's educational attainment, type of pregnancy(i.e.wanted or unwanted pregnancy), number of family members, and marital satisfaction (p < 0.05) (Table 3).These variables along with self-care performance were inserted into a multivariate linear regression model using the backward elimination strategy.Finally, self-care performance, woman's educational attainment, spouse's educational attainment, and the number of family members predicted 11% of the variance of participants' perceived stress during the COVID-19 pandemic period (Table 4).

Discussion
The aim of this study was to determine the self-care performance of Iranian pregnant women and its relationship with perceived stress during the COVID-19 pandemic period.The results indicated that 85% of the participants had a good self-care performance in preventing COVID-19 infection.The spouse's educational attainment, wanting to get pregnant, marital satisfaction, and housing status of pregnant women were signi cantly related to self-care performance.Higher educational attainment of husbands was associated with greater self-care performance of wives, because a more educated man transfers his knowledge and awareness to other family members and provides his pregnant wife with more support.In addition, women who had wanted pregnancy and those who were satis ed with their married life had higher levels of self-care performance.These issues highlight the important effect of family and children on women's performance.A woman who lived with her parents or with her husband's parents had lower levels of self-care performance compared with one who lived independently in a private or rented house.This is probably because a pregnant woman who lives with more people cannot take care of herself and follow all health protocols at all times.
This was the rst study to examine the self-care performance of pregnant women in preventing COVID-19 infection; thus, there was no similar study to compare with the present study.
The pregnant women had a moderate mean perceived stress score (25.5).This is in line with the ndings of Iranzad et al. and Kashanian et al. who measured Iranian pregnant women's perceived stress before the COVID-19 epidemic period (22,23).Epidemic and contagious diseases are stressful for all members of society, and pregnancy alone puts lots of stress on women; therefore, pregnant women are expected to have higher A signi cant inverse relationship was found between self-care performance and perceived stress scores, as self-care performance increased, perceived stress score decreased.In this respect, the strong mother-fetus bond may have encouraged mothers to better take care of themselves and fully adhere to health protocols to prevent COVID-19 infection, and this proper self-care may have in turn reduced their perceived stress.
Woman's education, spouse's education, and the number of family members predicted pregnant women's perceived stress levels, as higher educational attainment led to lower levels of stress.Higher levels of education may increase women's knowledge and understanding of COVID-19 infection, help them better protect themselves against the disease, and thereby reduce their perceived stress.This is in line with the results of  (25).These ndings are in line with the present results.
The higher number of family members also resulted in higher perceived stress levels, because in larger families, it is more likely for one to become infected with COVID-19 and transmit it to the rest of the family members; therefore, stress levels are higher in larger families.
The use of cluster sampling and random selection of health centers and pregnant women were among the strengths of the present research.All the answers of pregnant women to the questions of the questionnaires are considered correct, which is one of the limitations of the study.Besides, due to the cross-sectional nature of the study, the pregnant women's stress levels and self-care performance may change over time as a result of changing COVID-19 prevalence and mortality rates, or due to increasing awareness levels.

Conclusion
The results showed that Iranian pregnant women had moderate stress levels and good self-care performance in preventing COVID-19 during the outbreak of the disease.The high educational attainment of a pregnant woman and her husband predicted low stress levels.This indicates that high awareness and proper information about a disease and a sense of control over emotions and feelings in critical situations (like pandemics) reduce perceived stress.
High stress during pregnancy is associated with complications such as preterm delivery, preeclampsia, low Apgar scores, depression, etc.On the other hand, any factor that reduces stress during pregnancy can protect the mother and fetus from adverse pregnancy outcomes; therefore, provision of proper training to pregnant women and their husbands about COVID-19 infection and prevention strategies may effectively increase women's self-care performance, and thereby reduce their stress levels.
self-care performance and perceived stress based on multivariate linear regression (n stress levels during the COVID-19 epidemic, yet the present results did not support this assumption.A few studies have investigated pregnant women's health status during the COVID-19 epidemic.For example, the results of Alan et al. (in Turkey)(24), Khatri et al. (in India)(25), and Effati et al. (in Iran)(26) in assessing the effect of the COVID-19 disease pandemic on the mental health of pregnant women are almost in line with the results of present study on perceived stress.One can conclude that the pieces of training provided by the mass media and health centers may have successfully controlled negative emotions during this critical period.However, Johnbosco et al. reported high levels of stress in Nigerian pregnant women during this period(27), which may be attributed to the different research settings and sampling times.

Table 2
The status of self-care performance, perceived stress and their correlation in pregnant women (n = 228)

Table 3
levels in women with greater educational attainment(26).This discrepancy can be attributed to the differences in the number of highly educated people in both studies, and differences in sampling times.The present study was carried out about 8 months after the onset of the COVID-19 pandemic, at a time that the level of public awareness about this disease was relatively high.In the study ofKhatri et al.in India, most pregnant women had a moderate stress level during COVID-19 pandemic, and perceived stress scores had no signi cant relationship with the variables of age, gestational age, and gravity Kingston et al.(28), Wang et.al(29) Salmalian et al. (30) and Fallahzadeh et al(31).Effetian et al. enrolled 205 pregnant women visiting health centers of Tabriz for mental health assessment during the COVID-19 pandemic, and found that variables of woman's education, spouse's education, marital satisfaction, and family income can predict pregnant women's stress levels.Unlike the present study, Effeti et al. observed higher stress