Coronavirus (COVID- 19) has challenged the health care system around the world. One of the main concerns about the disease is coronavirus's impact on pregnancy and its risk for pregnant women and their children (22). The pregnancy period alone is stressful and full of worries, and recently, the anxiety and worry were added by coronavirus's epidemic (10). What seems important these days is the formation of relationships and the emergence of behaviors that indicate society's critical nature, which can affect all aspects of people's lives. To the best of our knowledge, no research has been found to examine the relationship between these variables in pregnant women during the epidemic.
In the present study, path analysis showed that during the coronavirus epidemic, the QoL of pregnant women was associated with SF, anxiety, depression, coronavirus disease anxiety, GH, and MS.
Ferreira et al., 2012, concluded a significant relationship between sexual performance and QoL in pregnant women (23). Also, in the study of Nik Azin et al., 2013, a direct relationship was found between QoL and sexual performance. In this way, people with high sexual function had a higher QoL, both of which correspond to the present study results (24).
Sex and marital relationship are changed due to the multiple physical and psychological changes during pregnancy (7); stress and anxiety caused by bad news, fear of infecting oneself and one's family with coronavirus, changes in lifestyle, and normal relationships. Concerns about the future are stressors that can reduce libido and impair sexual function (25). On the other hand, many people tend to have sex because of emotional motivation and insecurity. Numerous studies have shown that more sex leads to less stress (26). Since one of the important physical and psychological dimensions of women's QoL is the quality of people's sexual life, it can be concluded that people with the proper SF will have a better QoL.
Another result of the study was the inverse relationship between QoL and depression and anxiety, which is in line with some studies (27, 28) Hence, as depression increases, QoL decreases.
Anxiety and depression during the pregnancy are serious health problems (29). Due to the sudden outbreak of coronavirus, people do not have access to enough information about the disease. Anticipated concerns among pregnant women such as fear of infection and transmission from mother to fetus, are common. As a result, the coronavirus can be expected to increase the risk of depression in pregnant women (30). Depression also causes adverse consequences of pregnancy and reduces the QoL by influencing the social and environmental psychology of QoL (28, 29).
The results of this study also showed that GH was more directly related to the QoL, and for the rest of the variables, they acted as intermediaries by relating to the impact GH on QoL. There is a negative and significant relationship between the QoL and mental health in pregnant women. In fact, due to the negative and I nverse correlation, it can be concluded that as QoL increases, the mental health of pregnant women decreases. Given that the high scores in the GHQ indicate a more mental disorder, the negative relationship between the two the variable shows that by increasing QoL scores, the scores of GHQ (mental disorder) decreased and this indicates that mental health is higher in women with a higher QoL.
The results of Nik Azin et al.'s 2013 study showed that there is a direct relationship between QoL, SF, and GH (24), and Fathi et al., 2013, also stated that there is a negative and significant relationship between GH and QoL in pregnant women (31), which are consistent with the results of the present study.
It should be noted that pregnancy is associated with significant changes in women's mental and physical health, and since social performance in pregnant women is lower than other members of society, it can have adverse effects on physical health, well-being, and QoL. (31, 32).
Many people, especially those at risk such as pregnant mothers, are forced to stay at home to prevent the coronavirus transmission. Long-term isolation or home-confinement may negatively affect psychosocial and mental health, especially causing stress, negative emotions, and impairing cognition. If prolonged, they may suppress the immune system and physiological functions. However, about 60% of pregnant women eliminate their physical activity during pregnancy, and it can be said that pregnancy causes women to stop their physical activity at this stage of life or reduce it. Besides, physical activity is directly related to the QoL and its dimensions. Hence, the QoL decreases with a decrease in physical activity (such as quarantine conditions). So, the study of Slimani et al. (2020) showed that physical activity was correlated with all QoL domains during a period of government-directed confinement and a limitation of personal freedom. It can be concluded that with government restrictions on home-confinement to reduce the incidence, can be expected that the physical activity of pregnant women will decrease compared to before the coronavirus epidemic, and therefore the QoL of pregnant women will decrease (32-36)
The present study results showed that anxiety, directly and indirectly, affects GH, depression, SF, MS, and QoL. to put it simply, pregnant women with a higher level of anxiety had a lower level of QoL.
Pregnancy is a special time, full of excitement and expectations, but for pregnant mothers, the coronavirus outbreak has caused fear, anxiety, and insecurity. Anxiety is a common symptom in patients with chronic respiratory distress that significantly reduces patients' QoL (33). Stress and anxiety can increase the risk of side effects during pregnancy, such as preterm birth, low birth weight, nausea and vomiting, low birth weight, and depression (10, 29).
In the present study, the results showed that coronavirus induced anxiety has both direct and indirect effects on QoL. Thus, pregnant women with higher levels of anxiety had better GH, lower SF, and higher levels of anxiety, depression, and obsession.
The results of Alipour et al., 2020, showed a correlation between coronavirus induced anxiety and GH. Thus, increasing the score on the physical and psychological symptoms of coronavirus induced anxiety was significantly associated with physical symptoms, depression anxiety, and social dysfunction, which is consistent with the results of the present study (16). Also, the results of studies conducted by Durankuş et al. 2020, and Wu et al. 2020, showed that the coronavirus disease epidemic affected the anxiety and depression of pregnant women, so that the level of anxiety and depression in pregnant women was higher during the epidemic (29, 30).
Pregnancy is a stressful time for pregnant women. The prevalence of coronavirus induced anxiety has increased stress and anxiety worldwide (29). Coronavirus anxiety is common, and as individuals are unfamiliar with it and generate cognitive ambiguity about the virus, it tends to increase more. Fear of the unknowns reduces the perception of immunity in humans and has always been a concern for humans (34).
Anxiety has always been endorsed by committed professionals as a health-threatening variable (37). Different types of anxiety disorders can have different effects on SF (38). The findings of a 2013 study by Nick Azin et al. showed that sexual desire and satisfaction were associated with aspects of QoL and mental health (anxiety, stress, and depression) in pregnant women (24). Anxiety has a limit, and if itexceeds, it can certainly have devastating effects, including exacerbating obsessive-compulsive behaviors. Obsessive behavior has increased during the coronavirus outbreak. Obsessive-compulsive disorder leads to decreased social, family functioning, and QoL (39). The results of a 1988 study by Karno et al. showed that people with the obsessive-compulsive disorder tend to rate themselves on a lower level of QoL (40).
Facing a crisis prevents a person from working and performing well on the components of problem-solving communication, emotional roles and reactions, emotional involvement (conflict), and behavioral control, which will lead to a decrease in public health and, consequently, the QoL in the individual (41).