Efforts and Expectations of Pregnant Women Against the Impact of the COVID-19 Pandemic: A Phenomenological Study

DOI: https://doi.org/10.21203/rs.3.rs-1954497/v1

Abstract

Background: COVID-19 is a global threat that directly impacts people's mental health and physical well-being. This study explores the efforts and expectations of pregnant women against the impact of the COVID-19 pandemic

Methods: This study was a qualitative study that used phenomenological methods and used a naturalistic approach. The informants of this study were pregnant women (n=20). Data analysis used content analysis with software (Nvivo Release 1.5).

Results: The results of the study are four themes namely increasing worries for pregnant women due to lack of knowledge about the impact of COVID-19; the efforts to reduce anxiety through spiritual, positive thoughts, and the role of the family; the efforts to prevent the pandemic exposure through reducing direct social relations, changing social life online, meeting nutritional, and strict health protocols; and the expectancy of pregnant women to the impact of the pandemic is the change in the health care system in health facilities.

Conclusion: The COVID-19 pandemic impacts the lives of pregnant women in a complex manner, mainly on anxiety. The efforts and expectations of pregnant women can be a reference in developing health service innovations in health facilities, especially pregnant women, to create a sense of physical and psychological security and comfort for pregnant women from the threat of COVID-19.

Background

COVID-19 is a global threat that directly impacts people's physical well-being and mental health 1–3. The World Health Organization (WHO) assesses that COVID-19 has an alarming impact on the level of spread and severity of the illness to the community, as indicated by the increase in cases reaching three times in all countries in early 2020 and frequently increasing until the end of 2020 from 221 countries with 2.2% Case Fatality Rate (CFR) mortality 4–6. In Indonesia, there were 735,124 confirmed cases of COVID-19 infection in 2020, with a death rate reaching 21944 (CFR 3%) 5.

The increased incidence of COVID-19 infections, which has a serious impact on the level of illness and death, has caused community psychosocial problems, such as acute panic, anxiety, stress, obsessive behavior, paranoia, and depression 1,7. The global prevalence of people from 25 countries showed 50.9% experiencing anxiety, 57.4% experiencing stress, and 58.6% experiencing depression 8. Shah et al. and Ozamiz-Etxebarria et al. explained that the increase in psychological problems during the COVID-19 pandemic was due to symptoms, comorbidities, and the length of the quarantine period 8,9.

The Centers for Disease Control and Prevention (CDC) states that pregnant women are a population vulnerable to being infected with COVID-19 with an increased risk of more severe disease and complications 10–12. Pregnant women are also more susceptible to COVID-19 infection than non-pregnant women due to their unique immunological conditions and changes in physiological adaptations during pregnancy 13,14. In addition, physiological changes in the respiratory system during pregnancy include increased levels of estrogen and progesterone, causing the respiratory tract to increase, which increases the risk of COVID-19 infection (respiratory pathogen) 15. Villar et al. stated that pregnant women diagnosed with COVID-19 had a higher risk of morbidity and mortality in mothers and neonates than pregnant women without a diagnosis of COVID-19 16. However, there is no evidence of vertical transmission of the COVID-19 virus to the fetus, but it increases the prevalence of premature birth in monitoring because COVID-19 can alter the maternal-fetal immune response, affecting the well-being of the mother and fetus 14.

Moreover, the COVID-19 pandemic makes pregnant women feel worried about being infected, and it impacts health during pregnancy for both mother and fetus 17,18. In line with research in Canada in 2020, pregnant women experienced anxiety (57%) and depression (37%); from 1987, pregnant women with high anxiety and depression were caused by more worries about the lives of mothers and fetuses against the threat of COVID-19 19. In addition, 82.5% of pregnant women were worried that during the delivery process, the baby would be infected with COVID-19 20. The condition of the psychological problems of pregnant women has worsened with the spread of information in the community, either from social media or online articles, about the high number of cases of COVID-19 infection, both among the general public and pregnant women 17,21. The lack of information related to COVID-19 and pregnancy has also put pregnant women uncertain about the effects of COVID-19 on their health and pregnancy 21,22.

Further, psychological problems experienced by pregnant women during the COVID-19 pandemic can produce serious outcomes in the form of psychopathology and stress that harm the mental health of pregnant women 23. This condition also becomes a cycle of maternal and fetal health problems in the long term that impacts children's cognitive and emotional development in the future 24,25. In addition, during pregnancy, psychological problems can inhibit fetal growth, premature birth, Intrauterine Fetal Death (IUFD), disability, and stunted neurodevelopment 26–28. Thus, pregnant women must be aware of their condition as humans are vulnerable to virus exposure and survive to stay healthy both physically and psychologically, especially during the COVID-19 pandemic. For this reason, this study aimed to explore the efforts and expectations of pregnant women regarding the impact of the COVID-19 pandemic, especially in the territory of Indonesia.

Methods

Study Design

This phenomenological qualitative research used a naturalistic approach. The natural approach is a suitable strategy for listening to and considering all information submitted by participants regarding actions and experiences, especially during the COVID-19 pandemic, to produce useful insights or information for others 29. Besides, qualitative research is inductive, from specific to general, to explain a phenomenon through the information available in the field 30.

Setting

This research was conducted in three provinces in Indonesia, namely the Special Region of Yogyakarta, Bangka Belitung Island, and Maluku. During the COVID-19 pandemic in the 2020–2021 period, infection cases reached 33,851 people, and 1,155 people died in Yogyakarta, 52,359 people and 1,462 people died (Bangka Belitung Island), and 18,555 people and 289 people died (Maluku) 31.

Study Participants

In-depth interviews were conducted with 20 pregnant women in three provinces, with details of the Special Region of Yogyakarta (n = 9), Bangka Belitung Island (n = 5), and Maluku (n = 6). Determining informants used a heterogeneous purposive sampling technique (education level, gestational age, area of residence, culture, and religion) to obtain complex diversity of information during the COVID-19 pandemic. The researchers also determined pregnant women as informants when the informants were willing to participate in the research process.

Data Collection

The researchers (AD, TS, and DTKD) conducted in-depth interviews on 20 pregnant women in one activity unless the researcher needed confirmation of unclear information. Before the in-depth interviews, the researchers distributed informed consent in a google form to obtain approval for the willingness and interview schedule (date and time). In-depth interviews were conducted using online media, namely, zoom and google meet. In in-depth interviews using a remote system, the informants are in their respective homes while the researchers are in Yogyakarta. Before the in-depth interview, the researchers reminded and sent messages in the form of date, time, and zoom link or google meet to 20 informants utilizing WhatsApp for in-depth interview activities.

In addition, researchers conducted in-depth interviews in a quiet and closed room using zoom or google meet for 1-1.5 hours using the national language (Indonesian). Before starting the in-depth interview, the researchers introduced themselves and asked the informant for permission to record in the form of a video and ensure the confidentiality of the data and visualization (image) of the informant, and then the informant was introduced. The researcher still made notes for the important keys during the in-depth interview process, even though the researcher had recorded them.

The in-depth interview process used a semi-structured interview guide with open-ended questions. One of the questions asked by the researchers was, "How do you minimize the anxiety you feel like a pregnant woman during the COVID-19 pandemic?". The questions in the interview guide went through a process of discussion and revision by the research team until the research team approved the interview questions. Furthermore, the researchers transcribed the recording of the in-depth interview in written form and translated it into English by a linguist to ensure that the sentence's meaning had the same meaning.

Data Analysis

Data analysis researchers used inductive content analysis to obtain new information or knowledge 32 from pregnant women, especially during the COVID-19 pandemic. Data analysis in this study utilized Nvivo Release 1.5 software to facilitate the categorization and coding process using transcripts 33. This analysis method is more flexible by comparing the categorization of concepts from themes and texts in the transcript. Researchers coded based on identifying concepts available in the transcript to answer research questions and then grouped them into themes. The theme analysis is summarized in Table 1. The researchers repeatedly carried out the coding process by the research team, which was then categorized into themes to produce an analysis of the agreed themes to answer the research questions.

Table 1. Summary of Theme Analysis

Sample Quotes

Items

Themes

"I am worried and very afraid of contracting COVID-19 because, during pregnancy, I do not know what the risks are like..."
  • Pregnant women feel more vulnerable.
  • Do not know the effect or risk of COVID-19 infection.
  • Perception of pregnant women: serious impact on fetal development and miscarriage.

Lack of knowledge about the impact of COVID-19 can increase the worries of pregnant women.

"... It is only strengthened by praying so that worries go away. Thus, thinking now that it is Covid… you have to pray if you are worried… it feels like you want to be carried away by the burden of your mind, so pray, and it is impossible for God not to want to help… there is still God. Hence, leave everything to God for whatever happens to us…."
  • Get closer to God (pray).
  • Positive thinking on the provisions of the COVID-19 pandemic.
  • Family support.

Efforts to reduce anxiety during the COVID-19 pandemic are through spiritual strength, positive thoughts, and the role of family.

“... for work problems that are urgent or arguably not urgent, we can meet via zoom or maybe a conversation meeting via google meet and WhatsApp, video calls… are transferred there. However, some things are required to be spoken face-to-face or must be done at work, of course trying to get to work….”
  • Reducing social relations with the environment.
  • Changing lives with social media.
  • Meeting nutritional needs.
  • Strict health protocols

Efforts to prevent pregnant women from being exposed to COVID-19

“… if that is the case, then we do not have to come all the way there (clinic) to avoid direct contact with people. If we go there, queuing… during that time, we meet many people… If such a (system) were put in place, it would help a lot….”
  • Virtual-based special antenatal care services.
  • Private antenatal care flow.

Changes in the health care system in antenatal care at the health facility and community level


Rigor of Study

Researchers considered the accuracy of research data through four tests: credibility, transferability, confirmability, and dependability 34. Researchers guaranteed the credibility of the research process with the approval of the ethics committee of Universitas Aisyiyah Yogyakarta. Informants were also willing to participate in the entire research process through in-depth interviews using online media and voice and image recording. The accuracy of copying the recording transcripts and using them as direct quotations strengthened the delivery of research results 35,36. In addition, the transcript results (verbatim) were analyzed using software for the coding process to get friends to answer research questions.

External validity with transferability: Researchers chose informants (pregnant women) from three provinces located on different islands to obtain data diversity (heterogeny) to get more complex information regarding the impact of the COVID-19 pandemic on the same population, namely pregnant women. In confirmability testing, researchers interpreted the data of the individual results based on researchers' understanding and insights. It was consistent in determining the code to obtain accurate data. In addition, the researchers compared the perspectives of one informant to another with various opinions or views of pregnant women during the COVID-19 pandemic. Moreover, the research team discussed the findings of the theme and ensured that the interpretation results could be interpreted. In the dependability stage, experts in qualitative research outside the research team audited the entire research process to ensure the research process was as planned to answer research questions.

Ethical Consideration

The research has received approval from the health research ethics committee of Universitas 'Aisyiyah Yogyakarta with No.1362/KEP-UNISA/I/2021. This research is also part of the Muhammadiyah Maternal and Child Center research program, Universitas Muhammadiyah Yogyakarta, to investigate the COVID-19 pandemic's effect on pregnant women. Informants in this study were completely voluntary to participate in the entire research process by signing the informed consent. In addition, informants received incentives in the form of money as internet package fees during the in-depth interview process.

Results

The results of in-depth interviews with pregnant women during the COVID-19 pandemic showed the efforts and hopes of pregnant women in supporting their health. Pregnant women made efforts to suppress the anxiety experienced through spiritual approaches, positive thinking, family support, and personal prevention efforts of pregnant women against COVID-19 exposure. The impact of COVID-19 affected the perception of pregnant women to expect a change in the health care system in health facilities, especially in antenatal care services through virtual care and home visits (Fig. 1). 

Table 2

Demographic Characteristics of the Informants

No.

Demographic informant

N = 20 (%)

1.

Geographic residence

    

Rural

8

(40)

Urban

12

(60)

2.

Province

    

Special Region of Yogyakarta (Java)

9

(45)

Bangka Belitung Islands (Sumatra)

5

(25)

Maluku (Sulawesi)

6

(30)

3.

Age of pregnant women

    

< 25 years

1

(5)

25–30 years

13

(65)

> 30 years

6

(30)

4.

Education level

    

High school

6

(30)

Collage

14

(70)

5.

Religion

    

Islam

14

(70)

Non-Islam

6

(30)

6.

Parity

    

Primigravida

10

(50)

Multigravida

10

(50)

7.

Gestational age

    

1st trimester

1

(5)

2nd trimester

13

(65)

3rd trimester

6

(30)

8.

ANC check-up

    

< 4

5

(25)

≥ 4

15

(75)

9.

Health facility

    

Clinic or Primary Health Centered (PHC)

11

(52.4)

Independent practice doctor

6

(28.6)

Hospital

4

(19)


Table 2 shows that most of the informants came from urban areas (60) in three provinces in Indonesia: the Special Region of Yogyakarta (Java Island), Bangka Belitung Island (Sumatra Island), and Maluku (Sulawesi Island)). Most informants were pregnant women aged between 25–30 years (65) with a college education level (70) and were Muslim (70). Most of the informants were in the second trimester of pregnancy (65), both primigravida and multigravida. In addition, the informant had performed an ANC 4 (75) examination at the clinic or PHC (52.4).

1. Lack of Knowledge about the Impact of COVID-19 Can Increase the Worries of Pregnant Women

Pregnant women were aware that conditions during pregnancy are more susceptible to infection with COVID-19, and also the lack of nutrition during pregnancy can reduce their immunity. The pregnant woman said:

"I fear that I am afraid of getting infected because they say pregnant women are more susceptible to getting the virus... because their immune system is lower..." (Informant 1).

"I am afraid because pregnant women are more vulnerable, while I do not eat enough… lately, that is what I think" (Informant 4).

The ignorance pregnant women regarding the impact of being infected COVID-19 made them worried about their health and the fetus. The pregnant woman said:

“My current concern is… thinking about the baby's development. Will it be affected if exposed to COVID-19?” (Informant 2).

"I am worried and very afraid of contracting COVID-19 because I do not know the risks" (Informant 3).

The lack of literacy about the impact of COVID-19 had made pregnant women perceived that exposure to COVID-19 in the early stages of pregnancy could be dangerous for the fetus. The pregnant woman said

"... I am afraid... if you are exposed to COVID-19, you will miscarry because it is still in the early stages of pregnancy..." (Informant 2).

2. Efforts to Reduce Anxiety During the COVID-19 Pandemic Through Spiritual Strength, Positive Thoughts, and the Role of Family

2.1. Get closer to God as a place to complain about the worries felt by pregnant women

Pregnant women tried to keep their minds and hearts calm to face the COVID-19 pandemic. They also took a spiritual approach. The pregnant woman said:

"I am so scared… However, I have to keep doing activities even though I am with many people. Therefore, I just pray a lot…” (Informant 5).

Pregnant women also tried to get closer to God as a place to share the worries. The pregnant woman said:

"I happen to be the type of person who gets stressed easily because of paranoia… thus, I pray more to God even if it is only in my heart, like oh God, I hope this COVID-19 problem does not come until us..." (Informant 6).

Believe that God will provide help made pregnant women's hearts and minds calmer and not to worry about being exposed to COVID-19. The pregnant woman said:

The pregnant mother said: "... Only strengthened by praying so that worries go away. Thus, thinking now that it is Covid… you have to pray if you are worried… it feels like you want to be carried away by the burden of your mind, so pray, and it is impossible for God not to want to help… there is still God. Hence, leave everything to God for whatever happens to us….” (Informant 7).

2.2. Positive thinking to the Creator of the universe for the provisions in life

Thinking positively that what happens is all by God’s will could reduce their worries of being infected with COVID-19. The pregnant woman said:

“… did not ask to get Covid… hence, we have not got it… we think again, we pray… if God wants to give it… and it turns out that it has not… it is impossible for God to give it to get Covid…” (Informant 4).

“Thinking is certain, just do not panic, you have to calm down and find a solution. We have to think positively, later, there will be a way…" (Informant 10).

2.3. Family support providing a sense of security and comfort

Family or husband’s support for pregnant women during the COVID-19 pandemic such as advice ,attention, and understanding their worried and paranoid could provide a sense of security and comfort for pregnant women. The pregnant woman said:

“It is a form of support for my family… Mom said, "Take care of your health, do not think about it too much… if you want to leave the house, you have to wear a mask.” They say to take care of your immunity because it is easy to get infected when pregnant. If the support from your husband's family says take care of your health, hopefully, during this pandemic, the delivery will be smooth without any disturbances…" (Informant 3).

“The most emotional support…, I feel like this… the feeling is like this, most husbands say calm down, especially during the time of covid so paranoia… so paranoid... he understands because he understands more (health workers) than we ordinary people. He explained well… do not worry. Hence, I calmed down a bit. He said the covid problem was okay, and the important thing was to be diligent in wearing masks because all of them were from droplets… so do not worry. Then, he also said to keep the condition with food control do not forget to take vitamins. If there are many or few covid patients, he will not say anything because he knows I am a panicky person… that is so paranoid…” (Informant 6).

3. Efforts to Prevent Pregnant Women from Being Exposed to COVID-19

3.1. Reducing direct social relations with the environment

The COVID-19 pandemic made pregnant women restricted their lives with the outside environment. The pregnant woman said:

“If there is an invitation, you have to find an excuse not to come. The body condition is also weak and vulnerable… Covid cases are also high, so most of them stay at home” (Informant 11).

“What kind of direction is it more… in the past when you met people you could chat… now you are like an introvert…. more scared than usual. Thus, more alert… more so than the ones here…” (Informant 13).

3.2. Changing social life with online media

The convenience of industry 4.0 in activities, communication, and social relations can support pregnant women in reducing contamination with the outside environment The pregnant woman said:

“… for work problems that are urgent or arguably not urgent; we can meet via zoom or maybe a conversation meeting via google meet and WhatsApp, video calls… be diverted there. However, some things are required to be spoken face-to-face or must be done at work, of course trying to get to work…" (Informant 2).

Pregnant women preferred to use online marketplaces, so they could limit the contact with people outside. The pregnant women said:

"Now I am just looking for information, prepare baby clothes ... this is half to death worrying ... if you go out, look at clothes online..." Informant 10).

“There is no sense of wanting to meet people. If you do not dare to leave the house, because it is delicious…. Sometimes, if no one is home, order food via grab...” (Informant 4).

Family communication remained smooth even with online media. The pregnant woman said:

“…if you are pregnant, you want to be close to your parents. Not so fussy that she said mama had to come, this had to be this. Thus, now and then, there are phone calls and video calls, now there is a pandemic, they are afraid they are under the virus…” (Informant 10).

3.3. Meeting nutritional needs during pregnancy

Pregnant women believed that meeting nutritional need during pregnancy was the right way to maintain a healthy body. Pregnant women said:

"I am afraid… if pregnant women are vulnerable… do not eat enough. Oh, I have to eat because there is a covid pandemic.... must eat a lot… must eat fruit…" (Informant 4).

3.4. Strict application of health protocols for self and husband

Pregnant women applied health protocols when leave the house such as using masks, hand sanitizer, washing hand, and reduce to touch public stuffs. The pregnant woman said:

"When you leave the house, you usually use a mask…the hand sanitizer is in your bag, you immediately wash your hands or spray the hand-sanitizer until your pants and the back of the motorbike are sprayed ..." (Informant 15).

"Back again, because of need, follow the health protocol and do not touch carelessly... must wear a mask..." (Informant 11).

Pregnant women believed that applied health protocol when was outside and arrived at home was the right way to prevent the transmission of COVID-19. The pregnant woman stated:

"Check with the doctor according to health protocols, such as keeping a distance, everyone wearing a mask…. seats follow the protocol, before entering you must wash your hands. I am just afraid that if you go to the supermarket and want to use a trolley, you have to spray it, go home, shower, and wash everything first… clean up…" (Informant 4).

4. Changes in the health care system in antenatal care at the health facility and community level

4.1. Virtual-based ANC services specifically for consulting

Virtual-based ANC services can provide convenience and comfort for pregnant women because it reduces the direct contact during the COVID-19 pandemic, and they also can perform this service in real-time without waiting for a scheduled visit. The pregnant woman said:

"…that is good. There is no need to go out there; you do not have to face it… it is more real-time. You do not have to go to the clinic. If you are pregnant, you have to have regular check-ups, you will continue to meet with the doctor, but if there is a virtual, it is safer…" (Informant 13).

Pregnant women felt that every ANC examination must be carried out with an ultrasound, so virtual services were not optimal for ANC services. The pregnant woman said :

“Actually, it is not optimal for pregnant women, because if it is a virtual feature… if you are curious, you cannot do an ultrasound. I do not think it is optimal for pregnant women. If it is a consultation… it is okay to talk, but it is not enough for further examination because nowadays it is more checked with ultrasound…" (Informant 1).

4.2. Private antenatal care flow in health facilities and the community

The fear of being exposed to COVID-19 made pregnant women expect that. the flow of ANC services from registration to the examination must be differentiated to ensure the health of pregnant women during the examination process. The pregnant woman said:

“… the hope is that the place to check for pregnant women… the route to the examination is different, the path for pregnant women who want to be examined in that way. If this cannot be distinguished… the hallways are still together; only the rooms are different, the queues, the waiting areas, and the prayer rooms are all still together. We hope that everything is devoted to pregnant and lactating mothers, we want our path to go to a different place, especially for pregnant people, then we make sure that all pregnant is healthy from Covid” (Informant 16).

In order to reduce the crowd, some health facilities enforce that only pregnant women can access from registration to ANC examination. The pregnant woman said:

"... no one can accompany, the accompany guy is waiting outside... the ultrasound results are only allowed to be video, but if you go to the hospital, you cannot... only patients can enter" (Informant 9).

ANC services empowered health cadres to take home visit monitoring to minimize COVID-19 transmission in health facilities.. The pregnant woman said:

"It is better if, for example, there are village cadres from the PHC who go to the houses of pregnant women than we have to gather in one place (posyandu)... we become victims (exposure to Covid-19) ..." (Informant 6).

Discussion

The findings of this study revealed that pregnant women experienced anxiety during the COVID-19 pandemic and a lack of knowledge regarding the impact of COVID-29 during the pregnancy process. Inadequate knowledge of pregnant women related to the risk of exposure to COVID-19 to mother and vertical transmission can increase negative attitudes toward preventing COVID-19 transmission37,38. Knowledge of pregnant women is mostly obtained from social media information, which has lower accuracy than information from health workers, newspapers, and the WHO or CDC website 37. Rumors, stigma, and conspiracies can affect the trust of pregnant women to misinformation and disinformation. The selection information must also be based on accurate and reliable source, so that health agencies and government stakeholders must be able to track misinformation in real-time39,40. Improving the literacy of pregnant women during the COVID-19 pandemic can help strive for prevention to strengthen the involvement of pregnant women in making decisions and empowering physical and psychological health 41..

During pregnancy, there is a transition process of physical dan emotional changes42,43. It can causes pregnant woman experienced real anxiety during the COVID-19 pandemic. This condition requires pregnant women to be more aware of "quality of life" in health based on physical, mental, and social subjects based on welfare 43. Self-efficacy is positively related in reducing anxiety 44,45. During the COVID-19 pandemic, pregnant women with high self-efficacy can easily seek effective way to handle their psychological stress and to face their problems 44,46.

Pregnant women practiced self-efficacy through internal and external approaches. Psychologically, pregnant women took an internal approach by getting closer to God and thinking positively during a pandemic and external approach through family support. Generally, health workers (56%) did not discuss regarding spiritual context when taking care of patients with anxiety47. Evans et al. also mentioned that midwives provided treatment for pregnant women with anxiety only through support, attention, and relaxation skills 48. A psychological approach through spirituality in handling individual anxiety related to belief in God, which is practiced in daily activities such as prayer, worship, and believing in God's commands, can foster hope, encouragement, and positive attitudes towards health problems. It showed that 91.7% of pregnant women who read the Qur'an experienced a decrease in anxiety 49. Curlin et al. added that strong spirituality impacted patients to cope health problems 47.

An external psychological approach showed that family support provided pregnant women with a sense of security and comfort during the COVID-19 pandemic. Tang et al. explained that low support from family and husband was one of the risk factors of anxiety in pregnant woman, with a prevalence of 91.86% 50. Low social and family support, also affected self-efficacy and the welfare of pregnant women 45. Yue et al. explained that family and partners support is crucial in reducing the adverse effects of pressure felt by pregnant women during the COVID-19 pandemic. Positive support could also provide an emotional experience 51.

Physically, pregnant women took internal and external approaches to prevent the transmission of COVID-19. This study showed that pregnant women avoided exposure to COVID-19 through an internal approach by implementing strict health protocols using online media to reduce direct interactions. Ames et al. explained the high cases of pregnant women with COVID-19 infection because they were unaware of their contact with the COVID-19 sufferer (76.8%) 52. pregnant women were also unaware of their condition because they did not show symptoms of exposure to COVID-19, so it was too late to take proper infection prevention and control 53.

Efforts to prevent COVID-19 transmission in community can be carried out by taking self-limiting steps in social interaction, limiting activities, and implementing health protocols (washing hands and wearing masks) 54.The implementation of social distancing and health protocols can reducing the spread of respiratory viral infections during the COVID-19 pandemic 55. Sikali’s research found out that social distancing has a negative impact, such as growing impersonality and individualism, and loss of sense of community because of social recection56. The negative impact of social distancing could be minimized by using social media as a replacement of direct interactions. Online interactions can also be implemented to maintain good relations in society, bring family closer and wider connections in the community 57–59.

An external physical approach was also carried out by pregnant women to meet nutritional needs during pregnancy. Pregnant women experience physiological and immunological changes that occur simultaneously, which can increase the risk and severity of infection. The condition is exacerbated by malnutrition during pregnancy14,60,61. Malnutrition lowers the immunity of pregnant women, thereby increasing susceptibility to disease and harming the survival of the mother and fetus 62,63. Fulfillment of nutrition throughout the life cycle applies to pregnant women because pregnancy is the most demanding period of nutritional needs, especially during the COVID-19 pandemic. COVID-19 has impact on changing eating behavior because optimal nutrition and food intake can strengthening the immune system, so they can prevent infectious diseases and inflammatory processes. 64,65

Despite efforts of pregnant women to prevent COVID-19 transmission, they also expect the government to guarantee their health by changing antenatal care services system, both at the health facility level and in the community. WHO has urged restrictions on providing health services and postponement of care for pregnant women as needed 66,67. Health monitoring does not run as before pandemic since the intensity of meetings with health workers is reduced 54,68. Restrictions for pregnant women in accessing health facilities should be replaced by optimizing virtual services that impact patient satisfaction 69–71. Telehealth services is an alternative for pregnant women to reduce their exposure to COVID-19 during prenatal care 72. Based on the findings, pregnant women expected a change in the flow of ANC services privately in health facilities and in the community with the role of health cadres to make home visit, so they do not need to visit health facilities.

Limitation of this study is about data collection had done by using Zoom and Google Meet. Unstable signal during in-depth-interview process causes researchers did not hear clearly of some information, so the researchers need to reconfirm the statements.

Conclusion

The COVID-19 pandemic has a complex impact on pregnant women, especially on anxiety about exposure to COVID-19. It is due to the low knowledge of pregnant women regarding the risk of exposure to COVID-19 pregnant women made various psychological and physical prevention efforts with internal and external approaches to improve their health and quality of life during the COVID-19 pandemic. Pregnant women expected that ANC services could change privately to prevent them from exposure to COVID-19 transmission. The efforts and hopes of pregnant women can be a reference in developing health service innovations for pregnant women, to create a sense of security and comfort from the threat of COVID-19.

Abbreviations

WHO

World Health Organization

CFR

Case Fatality Rate

CDC

Centers for Disease Control and Prevention

IUFD

Intrauterine Fetal Death

PHC

Primary Health Centered.

Declarations

Acknowledgment

Acknowledgment to the Research and Innovation Institute, Universitas Muhammadiyah Yogyakarta, which has funded the entire process of this research activity.

Authors’ Contribution 

AD contributed to an in-depth interview, developed a semi-structured interview guide, the design of the study, analysis, and reviewed the manuscript. TS developed a semi-structured interview guide, and reviewed the manuscript. S contributed to analysis, developed a semi-structured interview guide, and reviewed the manuscript. DTKD contributed to an in-depth interview, analysis and wrote the first draft of the manuscript. All authors have approved the final manuscript.

Funding

This study is funded by Research and Innovation Institute, Universitas Muhammadiyah Yogyakarta (No. 550/PEN-LP3M/II/2021).

Availability of Data and Materials 

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. 

Ethics Approval and Consent to Participate 

The research has received approval from the health research ethics committee of Universitas 'Aisyiyah Yogyakarta with No.1362/KEP-UNISA/I/2021. Informed consent was obtained from all participants. All participants in this study were completely voluntary to participate in the entire research process by signing the informed consent. The researchers distributed informed consent to each participant in a google form to obtain approval for the willingness and interview schedule (date and time). All methods were carried out in accordance with relevant guideline and regulations

Consent for Publication

Not applicable

Competing Interest 

The authors have no competing interests in this research.

References

  1. Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, et al. Epidemiology of mental health problems in COVID-19: a review. F1000Res. 2020;9:636.
  2. Wang C, Tee M, Roy AE, Fardin MA, Srichokchatchawan W, Habib HA, et al. The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia. PLOS ONE. 2021;16:e0246824.
  3. WHO. WHO Director-General’s opening remarks at the media briefing on COVID-19–11 March 2020 [Internet]. 2020 [cited 2022 Apr 6]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
  4. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic - PMC [Internet]. 2020 [cited 2022 Apr 12]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569573/
  5. Kementerian Kesehatan RI. Situasi Terkini Perkembangan Novel Coronavirus (Covid-19): Data dilaporkan sampai 30 Desember 2020 [Internet]. 2020 [cited 2022 Apr 12]. Available from: https://infeksiemerging.kemkes.go.id/document/situasi-terkini-perkembangan-covid-19-31-desember-2020/view
  6. WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 38 [Internet]. World Health Organization; 2020. Available from:
  7. Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr. 2020;14:779–88.
  8. Shah SMA, Mohammad D, Qureshi MFH, Abbas MZ, Aleem S. Prevalence, Psychological Responses and Associated Correlates of Depression, Anxiety and Stress in a Global Population, During the Coronavirus Disease (COVID-19) Pandemic. Community Ment Health J. 2021;57:101–10.
  9. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain. Cad Saude Publica. 2020;36:e00054020.
  10. CDC. COVID-19 Information for Specific Groups of People [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2022 Apr 13]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html
  11. WHO. Coronavirus disease (COVID-19) [Internet]. 2022 [cited 2022 Apr 13]. Available from: https://www.who.int/health-topics/coronavirus
  12. Wyper GMA, Assunção R, Cuschieri S, Devleesschauwer B, Fletcher E, Haagsma JA, et al. Population vulnerability to COVID-19 in Europe: a burden of disease analysis. Archives of Public Health. 2020;78:47.
  13. CDC. Pregnant and Recently Pregnant People [Internet]. Centers for Disease Control and Prevention. 2022 [cited 2022 Apr 13]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html
  14. Liu H, Wang LL, Zhao SJ, Kwak-Kim J, Mor G, Liao AH. Why are pregnant women susceptible to COVID-19? An immunological viewpoint. J Reprod Immunol. 2020;139:103122.
  15. Vale AJM, Fernandes ACL, Guzen FP, Pinheiro FI, Azevedo EP de, Cobucci RN. Susceptibility to COVID-19 in Pregnancy, Labor, and Postpartum Period: Immune System, Vertical Transmission, and Breastfeeding. Front Glob Womens Health [Internet]. 2021 [cited 2022 Apr 13]; Available from: https://www.frontiersin.org/articles/10.3389/fgwh.2021.602572/full
  16. Villar J, Ariff S, Gunier RB. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. 2021;175:817–26.
  17. Dewi A, Safaria T, Wenang S, Dewanto I, An AD, Dewi DTK. The COVID-19 Pandemic: How Does It Affect Pregnant Women? Open Access Macedonian Journal of Medical Sciences [Internet]. 2022 [cited 2022 Feb 10];9. Available from: https://oamjms.eu/index.php/mjms/article/view/7838
  18. Moyer CA, Compton SD, Kaselitz E, Muzik M. Pregnancy-related anxiety during COVID-19: a nationwide survey of 2740 pregnant women. Arch Womens Ment Health. 2020;23:757–65.
  19. Lebel C, MacKinnon A, Bagshaw M, Tomfohr-Madsen L, Giesbrecht G. Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. Journal of affective disorders [Internet]. 2020 [cited 2022 Apr 14];277. Available from: https://pubmed.ncbi.nlm.nih.gov/32777604/
  20. Akgor U, Fadıloglu E, Soyak B, Unal C, Cagan M, Temiz BE, et al. Anxiety, depression and concerns of pregnant women during the COVID-19 pandemic. Arch Gynecol Obstet. 2021;304:125–30.
  21. Keating NE, Dempsey B, Corcoran S, McAuliffe FM, Lalor J, Higgins MF. Women’s experience of pregnancy and birth during the COVID-19 pandemic: a qualitative study. Ir J Med Sci. 2021;1–8.
  22. Meaney S, Leitao S, Olander EK, Pope J, Matvienko-Sikar K. The impact of COVID-19 on pregnant womens’ experiences and perceptions of antenatal maternity care, social support, and stress-reduction strategies. Women and Birth [Internet]. 2021 [cited 2022 Apr 13]; Available from: https://www.sciencedirect.com/science/article/pii/S1871519221000792
  23. Puertas-Gonzalez JA, Mariño-Narvaez C, Peralta-Ramirez MI, Romero-Gonzalez B. The psychological impact of the COVID-19 pandemic on pregnant women. Psychiatry Res. 2021;301:113978.
  24. Kofman YB, Eng ZE, Busse D, Godkin S, Campos B, Sandman CA, et al. Cortisol reactivity and depressive symptoms in pregnancy: The moderating role of perceived social support and neuroticism. Biol Psychol. 2019;147:107656.
  25. Rathbone AL, Prescott J. Pregnancy-specific health anxiety: symptom or diagnosis? British Journal of Midwifery. 2019;27:288–93.
  26. Bjelica A, Cetkovic N, Trninic-Pjevic A, Mladenovic-Segedi L. The phenomenon of pregnancy — a psychological view. Ginekologia Polska. 2018;89:102–6.
  27. Fischbein RL, Nicholas L, Kingsbury DM, Falletta LM, Baughman KR, VanGeest J. State anxiety in pregnancies affected by obstetric complications: A systematic review. Journal of Affective Disorders. 2019;257:214–40.
  28. Seyed Ahmadi Nejad FS, Golmakani N, Asghari Pour N, Shakeri MT. Effect of Progressive Muscle Relaxation on depression, anxiety, and stress of primigravid women. Evidence Based Care. 2015;5:67–76.
  29. Beuving J, Vries G de. Doing Qualitative Research The Craft of Naturalistic Inquiry. Amsterdam: Amsterdam University Press; 2014.
  30. Merriam SB, Tisdell EJ. Qualitative Research: A Guide to Design and Implementation. San Francisco: Jossey-Bass A Wiley Brand; 2016.
  31. Kementerian Kesehatan RI. Situasi Terkini Perkembangan Coronavirus Disease (COVID-19) 25 November 2021 [Internet]. 2021 [cited 2022 Apr 7]. Available from: https://infeksiemerging.kemkes.go.id/situasi-infeksi-emerging/situasi-terkini-perkembangan-coronavirus-disease-covid-19-25-november-2021
  32. Patton MQ. Qualitative research and evaluation methods. 3 ed. Thousand Oaks, Calif: Sage Publications; 2002. 598 p.
  33. Flick U, editor. The Sage handbook of qualitative data collection. Los Angeles: Sage Reference; 2018. 708 p.
  34. McInnes Susan, Peters Kath Peters, Bonney Andrew, Halcomb E. An Exemplar of Naturalistic Inquiry in General Practice Research. Nurse researcher [Internet]. 2017 [cited 2020 May 2]; Available from: https://pubmed.ncbi.nlm.nih.gov/28102791/?from_term=what+is+naturalistic+in+qualitative+research+methods&from_pos=9
  35. Thomas E, Magilvy JK. Qualitative Rigor or Research Validity in Qualitative Research. Journal for Specialists in Pediatric Nursing. 2011;16:151–5.
  36. Tuckett AG. Part II. rigour in qualitative research: complexities and solutions. Nurse Res. 2005;13:29–42.
  37. Izhar R, Husain S, Tahir MA, Husain S, Hussain S. Pregnant during the COVID-19 pandemic: Knowledge, concerns, attitudes and practices of Pakistani women. Eur J Midwifery. 2021;5:1–9.
  38. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. International Journal of Biological Sciences. 2020;16:1745.
  39. Fridman I, Lucas N, Henke D, Zigler CK. Association Between Public Knowledge About COVID-19, Trust in Information Sources, and Adherence to Social Distancing: Cross-Sectional Survey. JMIR Public Health Surveill. 2020;6:e22060.
  40. Islam MS, Sarkar T, Khan SH, Mostofa Kamal AH, Hasan SMM, Kabir A, et al. COVID-19–Related Infodemic and Its Impact on Public Health: A Global Social Media Analysis. Am J Trop Med Hyg. 2020;103:1621–9.
  41. Choukou MA, Sanchez-Ramirez DC, Pol M, Uddin M, Monnin C, Syed-Abdul S. COVID-19 infodemic and digital health literacy in vulnerable populations: A scoping review. DIGITAL HEALTH. 2022;8:20552076221076930.
  42. Farrell T, Reagu S, Mohan S, Elmidany R, Qaddoura F, Ahmed EE, et al. The impact of the COVID-19 pandemic on the perinatal mental health of women. J Perinat Med. 2020;48:971–6.
  43. Lagadec N, Steinecker M, Kapassi A, Magnier AM, Chastang J, Robert S, et al. Factors influencing the quality of life of pregnant women: a systematic review. BMC Pregnancy and Childbirth. 2018;18:455.
  44. Cui C, Zhai L, Sznajder KK, Wang J, Sun X, Wang X, et al. Prenatal anxiety and the associated factors among Chinese pregnant women during the COVID-19 pandemic——a smartphone questionnaire survey study. BMC Psychiatry [Internet]. 2021 [cited 2022 Apr 23];21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8661313/
  45. Izadirad H, Niknami S, Zareban I, Hidarnia A. Effects of Social Support and Self-Efficacy on Maternal Prenatal Cares Among the First-Time Pregnant Women, Iranshahr, Iran. J Family Reprod Health. 2017;11:67–73.
  46. Dule A. Psychological Distress Among Ethiopian Pregnant Women During COVID-19: Negative Correlation with Self-Efficacy. Psychol Res Behav Manag. 2021;14:1001–10.
  47. Curlin FA, Lawrence RE, Odell S, Chin MH, Lantos JD, Koenig HG, et al. Religion, spirituality, and medicine: psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. Am J Psychiatry. 2007;164:1825–31.
  48. Evans K, Spiby H, Morrell CJ. Developing a complex intervention to support pregnant women with mild to moderate anxiety: application of the Medical Research Council framework. BMC Pregnancy and Childbirth. 2020;20:777.
  49. Mokhtaryan T, Yazdanpanahi Z, Akbarzadeh M, Amooee S, Zare N. The impact of Islamic religious education on anxiety level in primipara mothers. J Family Med Prim Care. 2016;5:331–7.
  50. Tang X, Lu Z, Hu D, Zhong X. Influencing factors for prenatal Stress, anxiety and depression in early pregnancy among women in Chongqing, China. J Affect Disord. 2019;253:292–302.
  51. Yue C, Liu C, Wang J, Zhang M, Wu H, Li C, et al. Association between social support and anxiety among pregnant women in the third trimester during the coronavirus disease 2019 (COVID-19) epidemic in Qingdao, China: The mediating effect of risk perception. Int J Soc Psychiatry. 2021;67:120–7.
  52. Ames JL, Ferrara A, Avalos LA, Badon SE, Greenberg MB, Hedderson MM, et al. COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California. PLOS ONE. 2021;16:e0256891.
  53. Khoury R, Bernstein PS, Debolt C, Stone J, Sutton DM, Simpson LL, et al. Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers. Obstet Gynecol. 2020;136:273–82.
  54. Goyal M, Singh P, Melana N. Review of care and management of pregnant women during COVID-19 pandemic. Taiwan J Obstet Gynecol. 2020;59:791–4.
  55. Kim MC, Kweon OJ, Lim YK, Choi SH, Chung JW, Lee MK. Impact of social distancing on the spread of common respiratory viruses during the coronavirus disease outbreak. PLOS ONE. 2021;16:e0252963.
  56. Sikali K. The dangers of social distancing: How COVID-19 can reshape our social experience. J Community Psychol. 2020;10.1002/jcop.22430.
  57. Chen YRR, Schulz PJ. The Effect of Information Communication Technology Interventions on Reducing Social Isolation in the Elderly: A Systematic Review. J Med Internet Res. 2016;18:e18.
  58. Delello JA, McWhorter RR. Reducing the Digital Divide: Connecting Older Adults to iPad Technology. J Appl Gerontol. 2017;36:3–28.
  59. Long E, Patterson S, Maxwell K, Blake C, Pérez RB, Lewis R, et al. COVID-19 pandemic and its impact on social relationships and health. J Epidemiol Community Health. 2022;76:128–32.
  60. Abu-Raya B, Michalski C, Sadarangani M, Lavoie PM. Maternal Immunological Adaptation During Normal Pregnancy. Frontiers in Immunology [Internet]. 2020 [cited 2022 Apr 27];11. Available from: https://www.frontiersin.org/article/10.3389/fimmu.2020.575197
  61. WHO. WHO guidelines on preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries. [Internet]. Geneva: World Health Organization; 2011 [cited 2022 Apr 28]. Available from: http://www.who.int/maternal_child_adolescent/en/
  62. Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onis M de, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. 2008;371:243–60.
  63. Young MF, Ramakrishnan U. Maternal Undernutrition before and during Pregnancy and Offspring Health and Development. ANM. 2020;76:41–53.
  64. Aman F, Masood S. How Nutrition can help to fight against COVID-19 Pandemic. Pak J Med Sci. 2020;36:S121–3.
  65. Rodriguez-Leyva D, Pierce GN. The Impact of Nutrition on the COVID-19 Pandemic and the Impact of the COVID-19 Pandemic on Nutrition. Nutrients. 2021;13:1752.
  66. WHO. Mempertahankan layanan kesehatan esensial: panduan operasional untuk konteks COVID-19 [Internet]. WHO Press; 2020. Available from: https://creativecommons.org/licenses/by-ncsa/3.0/igo
  67. Kementrian Kesehatan RI, Direktorat Jenderal Kesehatan Masyarakat. Pedoman Pelayanan Antenatal, Persalinan, Nifas, dan BBL di Era Adaptasi Kebiasaan Baru. Jakarta: Kementerian Kesehatan RI; 2020. 112 p.
  68. Farizi S. Pandemi dan Krisis Pelayanan Kesehatan Ibu Hamil [Internet]. detiknews. 2020 [cited 2020 Dec 23]. Available from: https://news.detik.com/kolom/d-5190787/pandemi-dan-krisis-pelayanan-kesehatan-ibu-hamil
  69. Fryer K, Delgado A, Foti T, Reid CN, Marshall J. Implementation of Obstetric Telehealth During COVID-19 and Beyond. Matern Child Health J. 2020;24:1104–10.
  70. Peahl AF, Smith RD, Moniz MH. Prenatal care redesign: creating flexible maternity care models through virtual care. Am J Obstet Gynecol. 2020;223:389.e1-389.e10.
  71. Tendean AF, Dewi A, Wirasto A. The Implementation of Antenatal Care with Telehealth Towards Pregnant Women’s Mental Health. JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit). 2021;10:103–18.
  72. Aziz A, Zork N, Aubey JJ, Baptiste CD, D’Alton ME, Emeruwa UN, et al. Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic. Am J Perinatol. 2020;37:800–8.