Awareness of Coronavirus Disease From Conception to Delivery: Antenatal Mental Journey Breaking Anxiety During Outbreak

Purpose The objective of this study was to evaluate the psychological impact of the coronavirus disease on women sensitized by pregnancy after the rst case was conrmed in Turkey, which has been declared a pandemic by the World Health Organization. This study also intends to help developing preventive measures for pregnants, reducing infection incidence, developing solutions to protect public health, and establishing whether pregnants have sucient knowledge and awareness to manage this situation. Methods This prospective study was conducted at two centers. A total of 529 pregnant women from all three trimesters were given questionnaires that consisted of 51 original questions. Results These results show the distribution of the participants’ responses to the 15 questions asked to measure anxiety regarding COVID-19 in pregnant women. Based on the responses, we created a scoring system to determine the level of anxiety in pregnant women. Every correct response measuring anxiety was a scale for and then assessed. Percentile


Introduction
The coronavirus disease (COVID-19) pandemic started on December 31, 2019, in the Chinese city of Wuhan, the capital of Hubei province [1]. On January 30, 2020, the World Health Organization reported that the COVID-19 outbreak was a public health emergency of international concern. As of May 30, 2020, the virus, which has rapidly spread across the country and around the world, has become a very serious issue and public health problem, with 6,099,000 cases, 369,000 deaths, and 2,700,000 recovered cases in approximately 6 months.
In Turkey, the rst case was reported on March 11, 2020, which was later than in other developing countries owing to the precautions taken prior to the emergence of the rst case. As of May 30, 2020, 163,103 cases, 4,515 deaths, and 126,000 recovered cases have been reported in Turkey [2].
The questionnaire comprises 51 original questions that investigate the pregnant women's demographic data, history of contact with COVID-19-positive patients, knowledge and concerns about COVID-19, precautionary measures, and approach to outbreak.
A link to the online questionnaire (SurveyMonkey) was sent to the pregnant participants, who were admitted to the obstetric outpatient clinics at Umraniye and Kanuni Sultan Suleyman Training Research Hospitals. The online questionnaire was sent to 529 women, out of whom 526 returned completed surveys.
The questionnaire was delivered using the QR code method and lled online to avoid contamination during this risky time. To assess the level of anxiety, only one of the questions used the Beck Anxiety Scale [7].
Adolescent pregnant women and pregnant women with diagnosed depression, anxiety, and psychosis were excluded from the study. Illiterate pregnant women and pregnant women with diagnosed or suspected COVID- 19 were not included in the study. A total of 529 pregnant women aged 18-48 years who volunteered to participate in the survey study were nally included.
Comparisons were made in terms of age, educational background, number of children, contact history, pregnancy week, risk factors, and anxiety and awareness levels. The results are intended to shed light on the measures taken by the Ministry of Health of the Republic of Turkey and contribute to informing and guiding healthcare workers and patients.
The statistical analyses were performed using the Statistical Package for the Social Sciences, version 25 (SPSS Inc.). Along with the descriptive statistical methods for data analysis, the Shapiro-Wilk test and boxplot graphs were used to test the normality of variables in terms of normal distribution. One-way analysis of variance was used in intergroup comparisons of normally distributed variables, while the Bonferroni test was used to determine groups with differences. The Kruskal-Wallis test was used for intergroup comparisons of non-normally distributed parameters, while Dunn's test was used to determine the groups with differences. The Mann-Whitney U test was used to compare the parameters between two groups. P < 0.05 was considered statistically signi cant.

Results
The study was conducted between March 30 and May 30, 2020, with a total of 526 participants aged 18-43 years with a mean age of 28.35 (SD: 5.43) years.
Of the pregnant women, 7% were healthcare workers. In terms of the number of children that they had, 45.8% were pregnant for the rst time; 32.7% had one child, 12.7% two children, and 87% had ≥ 3 children.
A total of 97.5% of the respondents were married. In terms of educational background, 14.1% were primary school graduates, 17.9% were secondary school graduates, 24.7% were high school graduates, 12.7% had associate degrees, and 30.6% had undergraduate and graduate degrees.
Of the respondents, 87.3% were non-smokers. In terms of pregnancy week, 23.8% were in gestation week 14,29.5% were in gestation week 14-28, and 46.7% were in gestation week > 28.
In terms of the number of people living in the household, 43% responded 1-2 people, 49.1% responded 3-5 people, and 14.6% responded 5-10 people. Those who had been admitted at the emergency service 1-5 times over the past year accounted for 49.1% of all included cases, and those admitted 5-10 times accounted for 14.6%. Those with a history of contact with an individual suspected of COVID-19 in the previous 14 days accounted for 1.5% of the cases, while those who were not sure of contact accounted for 3.4%. Public transport use rate over the past month was 23%. In addition, 49% of participants touched their faces less than 10 times a day, while 40.5% touched their faces more than 10 times a day. Moreover, 20.2% of the participants did not undergo routine pregnancy checks, 18.8% did so occasionally, and 61% did so regularly.
A total of 8.7% of the participants believed that the use of antibiotics is effective against COVID-19.
Additionally, 53% thought that social media was being e ciently used to inform the society about COVID-19, and 4.9% of the cases had been previously vaccinated against in uenza.
Those who thought that they were well informed about how COVID-19 is transmitted accounted for 77.4% of the participants; those who thought that they were well informed about its symptoms also accounted for 77.4%. Further, 86.1% of the participants thought that the most important symptom of COVID-19 is fever, while 62.5% thought it is cough, 70.7% shortness of breath, and 6.1% other symptoms. In addition, 56.3% of the participants stated that they would be interested in getting vaccinated if there was a vaccine against COVID-19, 18.1% thought that their families and friends were well informed about COVID-19, 67.7% thought that the pandemic was preventable, 80.4% thought the pandemic was deadly, 58.4% found the measures taken by the Ministry of Health against the pandemic to be satisfactory, and 33.1% were informed by healthcare workers.
Among the measures taken by the participants against the COVID-19 pandemic, frequent hand washing was 88.6%, use of hand sanitizer/cologne was 59.9%, avoiding crowds was 83.3%, wearing a mask was 61.6%, wearing gloves was 26.4%, and staying home for protection was 3.2%.
Among the measures taken to reduce the number of cases and deaths related to COVID-19 in Turkey, most were those taken by the Ministry of Health, which accounted for 23%. This was followed by staying home unless necessary (19.2%) and cleaning habits (16.2%). Furthermore, 93.5% of the participants expressed that they would perform self-protection by quarantining themselves at home for 14 days if they came in contact with individuals with suspected COVID-19, 96.4% expressed that they would not visit any relative or friend within the rst 14 days following their arrival from other countries. 86.9% stated that they were following up-to-date information about COVID-19 in Turkey and around the world, and 24.7% thought the COVID-19 pandemic was overrated. Additionally, 51.1% of the participants thought that they needed to be informed about COVID-19, 42.4% stated they would accept inpatient treatment if recommended by their doctor because of COVID-19, 51% stated they would provide swab samples if requested by their doctor after they had contacted an individual diagnosed with COVID-19, and 42.7% stated that they would share their diagnosis of COVID-19 with everyone if diagnosed with COVID-19.
The results outlined above include the distribution of the responses given by the pregnant women to the 19 questions asked to assess their awareness of COVID-19. A scoring system of 19 questions to determine the level of awareness in pregnant women was created. Every correct answer indicating awareness was converted into a hundred-point scale for standardization. Percentile values ranked at the 33.3 and is categorized as average, and awareness was classi ed. The scores of awareness of COVID-19 were 5.26-100, with a mean score of 60.13 ± 14.81. Of the participants, 3.6% who scored 33.3 and below had low awareness, 58.7% who scored 33.3-66.6 had moderate awareness, and 37.6% who scored ≥ 67 had high awareness. (Table 1) There was no statistically signi cant relationship between age and scores of COVID-19 awareness.
(r=-0,016; p = 0,712; p > 0,05). There was also no statistically signi cant difference between the scores of COVID-19 awareness in terms of educational background (p > 0,05). There was no signi cant difference among the scores of COVID-19 awareness in terms of being a healthcare worker or not (p > 0,05). In terms of number of children, however, there was a signi cant difference among the scores of COVID-19 awareness (p < 0.05): the awareness increased as the number of children increased. The awareness score of women who had no children was signi cantly lower than that of those who had three children (p = 0,016; p < 0,05).
In terms of use of public transport in the previous 1 month, there was no signi cant difference among the scores of COVID-19 awareness (p > 0,05).

Page 7/22
There was no signi cant difference among the scores of COVID-19 awareness in terms of having contacted anyone with suspected COVID-19 in the previous 14 days (p > 0,05). There was also no signi cant difference among the scores of COVID-19 awareness in terms of pregnancy week (p > 0,05). There was a signi cant difference among the scores of COVID-19 awareness in terms of the number of people living in the household (p < 0.05); the awareness score of those with a household of 1-2 people was signi cantly lower than that of those with a household of 3-5 people (p:0,012; p < 0,05). There was a signi cant difference among the scores of COVID-19 awareness in terms of visiting the healthcare facility for routine pregnancy check-ups (p < 0.05); the awareness score of those continuing routine pregnancy check-ups was signi cantly higher than that of those not undergoing or occasionally undergoing routine pregnancy check-ups (p:0,001; p < 0,01). (Table 2) In terms of the risk factors of pregnant women, the scores of COVID-19 awareness did not signi cantly differ in other groups of risk factors, except for those with heart disease (p > 0.05). The awareness score of patients with heart disease was signi cantly higher than that in those without heart disease (p < 0.05) ( Table 3). These results show the distribution of the participants' responses to the 15 questions asked to measure anxiety regarding COVID-19 in pregnant women. Based on the responses, we created a scoring system to determine the level of anxiety in pregnant women. Every correct response measuring anxiety was converted into a hundred-point scale for standardization and then assessed. Percentile values ranked at the 33.3 and is categorized as average, and anxiety was classi ed.
The scores of COVID-19 anxiety ranged from 13.33 to 86.67, with a mean score of 53.49 ± 13.63. Those with a score of ≤ 33.3 were classi ed as having low anxiety and accounted for 11.4% of the respondents; those with scores of 33.3-66.6 had a moderate level of anxiety and accounted for 66.2% of the respondents, and those with a score of ≥ 67 had a high level of anxiety and accounted for 22.4% of the respondents. (Table 4) High Anxiety Levels 118 (22,4) There was no statistically signi cant relation between age and score of COVID-19 anxiety (r=-0,043; p = 0,322; p > 0,05). There was also no signi cant difference among the scores of COVID-19 anxiety in terms of number of children and whether the participants were health workers or not (p > 0,05).
There was no statistically signi cant difference among the scores of COVID-19 anxiety in terms of public transport use over the past 1 month and educational background (p > 0,05). In terms of contact with an individual with suspected COVID-19 in the past 14 days, there was a signi cant difference among the scores of COVID-19 anxiety (p < 0.05). It was found that those with a history of contact had signi cantly higher anxiety scores than those without a history of contact (p = 0,014; p < 0,05).
There was a signi cant difference among the scores of COVID-19 anxiety in terms of gestation week (p < 0.05), with the highest level of anxiety in the 2nd trimester and lowest level of anxiety in the 1st trimester (p = 0,014; p < 0,05). In terms of household size, there was no signi cance among the scores of COVID-19 anxiety (p > 0,05). There was a signi cant difference among the scores of COVID-19 anxiety in terms of visiting the healthcare institution for routine pregnancy check-ups (p < 0.05). Those visiting regularly had signi cantly higher anxiety scores than those not visiting at all or visiting occasionally for routine pregnancy check-ups (p:0,008; p < 0,01). (Table 5) In terms of risk factors, the scores of COVID-19 anxiety did not differ signi cantly among the participants, except for those with DM (p > 0.05). Those with DM had signi cantly higher anxiety scores than those without DM (p < 0,05). (Table 6) Mann Whitney U test *p < 0,05 There was a statistically signi cant positive correlation between the scores of COVID-19 anxiety and the scores of COVID-19 awareness (r = 0,252; p = 0,001; p < 0,01). As the awareness level of pregnant women increased, the anxiety level increased as well. (Fig. 1)

Discussion
A total of 526 pregnant women from all three trimesters who were admitted to two centers in the Asian and European sides of Istanbul with the highest patient admissions were surveyed. Based on the data, 58.7% of the pregnant women were found to have moderate awareness. When the awareness rates of pregnant women with comorbidities were examined, it was found that the awareness levels of pregnant women with heart disease were higher. In total, 81.9% of the participants believed that they and their relatives were not su ciently informed about COVID-19, and 59.1% thought that healthcare workers did not inform them about the COVID-19 properly. In addition, 64.6% of the participants thought they needed information about COVID-19. These data suggest that considering that the impact of COVID-19 on prenatal and postnatal periods has yet to be proven [8], healthcare workers should further inform pregnant women about COVID-19.
Although 58.7% of the pregnant women thought that the measures implemented by the Ministry of Health from the beginning of the pandemic in Turkey were satisfactory, only 18.1% thought that they were informed about how to protect and isolate themselves from the COVID-19 pandemic. These results are noteworthy and can encourage the Ministry of Health and healthcare workers to conduct more projects on informing people about the modes of transmission and protection against the virus.
While the COVID-19 awareness level is expected to increase as the level of education increases, there was no signi cant difference in the present study. This is consistent with the results obtained by Wang et al. According to their data, the anxiety rate was increased in patients with low educational background, whereas in our study, there was no positive correlation between educational background and anxiety [9].
Despite the fact that awareness levels increased as the number of children and the household size increased in the present study, there was no signi cant increase in the anxiety levels. In the study by Wang et al., a higher number of children and increased household size were not associated with increased awareness and anxiety [9]. Remarkably, based on data obtained in the current study, there was no signi cant difference between the awareness levels of healthcare worker women and non-healthcare worker women. 40.9% of the pregnant women expressed hesitation to report infection with COVID-19 to their physician and the Ministry of Health. This indicates that almost 50% of the pregnant women suffering from the disease try to avoid quarantine and do not understand the gravity of the situation. The concealment of a diagnosis puts the person's immediate environment and public health and healthcare workers at risk. It can be concluded that during the management of this process, it is necessary to provide the necessary psychosocial support and increase awareness of the COVID-19 pandemic among the public.
In terms of both anxiety and awareness scoring, those who visited the healthcare institution regularly for routine pregnancy check-ups had high levels of awareness and high anxiety scores. In addition, there was a statistically signi cant correlation between the scores of COVID-19 anxiety and awareness.
In our study, 66.2% of the participants were moderately concerned, while Saccone et al. found that 53% of respondents had been psychologically affected at a high level [10].
In terms of comorbidities, those with DM were more concerned about getting infected by the virus, while patients with cancer [11] and patients with chronic lung disease, who are thought to be more prone to stress and depression, did not have a signi cantly increased anxiety.
The period when anxiety was observed at the highest level was the 2nd trimester, whereas the lowest level was seen in the 1st trimester. On the contrary, in the study [10], the anxiety levels of pregnant women in the 1st trimester were higher. Mirzadeh and Khedmat particularly stressed that pregnant women need psychological support during this crisis [15].
Studies show that there is an increased predisposition to emotional state disorders in pregnancy and childhood [16,17,18]. Pregnant women experience more anxiety and suffer from fears that arise as the delivery date approaches during advanced gestation weeks [16]. It is also believed that if the concerns that pregnant women suffering from infectious diseases have about the health of their babies are added to this, their mental health can be affected even more.
Postpartum psychology has also been revealed to be adversely affected by symptoms of anxiety or depression due to infant phenotype and rejection of maternal role [17,18].
During the pandemic, women are under stress and may therefore complain about a large number of psychological symptoms or nonspeci c symptoms that can be confused with those of COVID-19. They can also face many obstetric or gynecological problems, such as emergence of unintended pregnancies.
In the present study, for example, it is noteworthy that 39% of the pregnant women avoided visiting the healthcare institution for routine pregnancy check-ups.
Because maternal anxiety prevents them from visiting obstetricians, poor obstetric consequences such as anomalous infant birth, intrauterine fetal demise, and increased rates of out-of-hospital birth may occur. Previous studies [4,19] support that pregnant women have more complications during the COVID-19 epidemic period than they had before the pandemic. Anxiety during pregnancy may be associated with many complications, such as preterm action [20,21], low birth weight, fetal growth restriction [21,22], and postnatal complications [23].

Limitations
A signi cant number of individuals who had been followed up or treated as outpatients or inpatients for con rmed or suspected cases of COVID-19 could not be surveyed as part of the present study since our hospital served as a major hospital during this pandemic. The duration of the study was prolonged to reach the targeted number of pregnant women due to the decrease in the number of patients admitted to outpatient clinics due to fear and anxiety. Patients who had di culty reading and understanding Turkish were not surveyed to avoid incorrect results. Owing to the high number of questions asked, some of the patients lled out the questionnaire by skipping some of the questions and some were unable to complete the questionnaire. Of all the pregnant women admitted to the emergency service, those who needed urgent diagnosis and treatment were not surveyed. Due to socioeconomic reasons such as not having access to internet or phone, some pregnant women could not be surveyed online.

Conclusions
The present study examined the paths considered by pregnant women at the time of crisis when they thought that they are facing COVID-19 and their attitudes regarding the vaccine yet to be developed. The participants were surveyed regarding whether they thought pregnancy is predisposed to infection and what ways they would resort to protect themselves and their family as well as whether they needed more information.
The pregnant women who completed the questionnaire were verbally warned to quit smoking if they were smokers, adopt a vitamin-rich diet to boost their immunity, and be careful about their self-care and hygiene. They were also informed that they could contact the District Health Directorates psychosocial support lines if they needed support.
However, it is believed that postpartum depression or psychosis can be aggregated with the COVID-19 pandemic.
COVID-19 anxiety in pregnancy can present as unwillingness to see the infant, avoidance of breastfeeding, self-harm, or harming others during the postpartum period. Mood swings and anxiety disorders during pregnancy can aggravate during the postpartum period if ignored and left untreated during pregnancy.
Maternal mental imbalance can also present as follows: a gradually increasing concern of getting infected can lead to their avoidance of postpartum pediatric and gynecological check-ups. Therefore, interventions such as phone calls or home visits are needed to increase patient tracking and prevent negative consequences that may arise from negligence.

Figure 1
Relationship between COVID-19's anxiety scores and awareness scores on pregnant women

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. COVID19questionnaire.docx