Mental health and marital satisfaction changes of pregnant and lactating women during the COVID-19 pandemic: A comparative cross-sectional study

Background: Women' mental health during reproductive age is a major public health concern in both developing and developed countries. There is a relationship between mental health and marital satisfaction. This study aimed to assess mental health, anxiety, depression, and marital satisfaction among pregnant and lactating women and compared the results with non-pregnant/lactating (as control group) during the COVID-19 pandemic in Iran. Methods: A cross-sectional study among married women in range of 18 to 45 years via online questionnaires was conducted from 20 March to 25 April, 2020. A total of 604 valid questionnaires were analyzed, including 200 pregnant women, 203 lactating women, and 201 non-pregnant/lactating women. Mental health, COVID-19-related anxiety, and marital satisfaction were respectively assessed by the General Health Questionnaire (GHQ), the Corona Disease Anxiety Scale (CDAS), and ENRICH Marital Satisfaction Scale (EMS Scale). The data were analyzed using Statistical Package for Social Sciences (SPSS) software. Results: The scores of mental health problems in pregnant and lactating women were signicantly higher than the control group (18.86±12.56 and 18.83±13.99 vs. 13.01±8.15, P<0.00). The total CDAS score in the control group was signicantly less than pregnant women (30.87±10.56 vs. 26.05±6.12, P<0.001) and lactating women (30.80±11.37 vs. 26.05±6.12, P<0.001). The mean of marital satisfaction was signicantly lower in the pregnant women (28.06±2.67 vs. 29.64±3.18, P < 0.001) and lactating women (28.74±3.58 vs. 29.64±3.18, p = 0.01) compared with the control group. There was no statistically signicant difference in the depression among three groups (P < 0.05). Conclusions: Pregnant and lactating women had more mental health problems, more anxiety and less marital satisfaction in comparison to non-pregnant/lactating women in the course of COVID-19 outbreaks. Further study is


Background
Due to uctuations and decline in the levels of ovarian hormones, women are at higher risk for mental health issues compared to men (1) and their mental health during reproductive age is a major public health concern in both developing and developed countries (2). There is an association between mental health status and marital satisfaction (3); anxiety and depression are associated with lower marital satisfaction (4,5). On the other hand, a satisfactory marital relationship prevents depression and psychological disorders, and improves the immune system (6,7). Pregnancy and childbearing has a major impact on the relationships and subsequently on marital satisfaction (8,9). Reduced marital satisfaction can lead to anxiety and depression in a pregnant woman and may have negative effects on the outcome of pregnancy (10,11). Women, who have a higher marital satisfaction, have a greater breastfeeding self-e cacy postpartum and are more likely to initiate and continue breastfeeding (12,13).
Ideally, pregnancy and having a baby, looking for a safe and positive pregnancy are events that are accompanied by joy and delight. However, some women may experience a range of negative emotions in course of this period (14). Almost all women can have mental disorders during pregnancy and in the rst year after childbirth, but emergency and con ict situations, natural disasters, extreme stress, and low social support can increase risks for speci c mental health disorders (15). Hence, it is acceptable that these women are vulnerable to mental disorders in the outbreaks of infectious diseases (16). The Covid-19 pandemic has created anxiety among pregnant women in different parts of the world (17,18).
Coronavirus Disease (COVID-19, also known as 2019-nCoV) has been announced as the sixth Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) (19). In December 2019, China was the rst country reporting the COVID-19 as the cause of an outbreak of a respiratory illness (20,21). In March 2020, a rapid surge in the number of infected people was observed across the world (22).
Previous studies have demonstrated that an outbreak of a novel or serious infectious disease is associated with worsened mental health (23,24). Hence, the spread of infectious diseases affects the psychological health and wellbeing of the infected and non-infected people, as well as the physical health of patients (25). The COVID-19 not only causes physical illness but also has a serious impact on people's mental health (26), such as anxiety, depressive symptoms, insomnia, and fear (27). This anxiety and depression may be due to social isolation, media information overload, limited access to basics, high mortality rate, discrimination, and disrupted travel plans (28,29).
In the Covid-19 pandemic, the concerns of pregnant women include: exposure to the COVID-19, planning their delivery, baby's birth, breastfeeding, neonatal care, and employees who constantly use sodium hypochlorite and alcohol (17).
Therefore, women can be vulnerable to mental health problems during pregnancy and in the rst year after childbirth within the COVID-19 outbreak. Also, based on the interaction between mental health and marital satisfaction, both mental health and marital satisfaction can be affected in the prevalence of COVID-19. The aim of this study was therefore to assess mental health, anxiety, depression, and marital satisfaction among pregnant and lactating women and compare the results with non-pregnant/lactating (as control group) during the COVID-19 pandemic in Iran.

Methods
According to the purpose of this study, a descriptive cross-sectional study, a comparison of three groups was To abide by quarantine for prevention of the COVID-19 spread, an online questionnaire was used to collect data. The online questionnaire creation software (porsline) was used. In this software, more than once the response by one person a mobile phone was prevented. The self-report online questionnaires, including: socio-demographic and obstetric information, General Health Questionnaire (GHQ), Corona Disease Anxiety Scale (CDAS), and ENRICH Marital Satisfaction Scale (EMS Scale).
Firstly, the valid questionnaires link (https://survey.porsline.ir/s/qahAeAY) was created and was sent through personal accounts on social media to all social groups that were only female. The objectives of the research, methods and potential outcomes were explained in the rst page of the survey. Data was directly stored in the online database upon completion of the survey by the participants. Convenience sampling method was used in this study.
Inclusion criteria were as follows: age range of 18 to 45 years, no history of chronic diseases (such as psychiatric illnesses, infertility, diabetes, cardiovascular disease, premature ovarian failure, hysterectomy), being married and living with husband, having sexual intercourse, not using any medications that is effective in the sexual response cycle (such as hormonal drugs, antidepressants, antihypertensive drugs, and antipsychotic drugs), and no current drug and alcohol abuse. Eligible women entered the study and were classi ed as one of the three groups of pregnant, lactating (delivered earlier < 1 year ago), and non-pregnant /lactating (delivered > 2 year ago).

Measures:
Socio-demographic and obstetric information were collected. These included: women's age, age at marriage, body mass index, province and city of residence, monthly income amount, educational level, duration of marriage, occupational status, gestational age (based on the week), gravidity, parity, number of live children, previous mode of delivery, and type of pregnancy (willing or unwilling).

Mental Health
The General Health Questionnaire (GHQ) was used to identify potential or at-risk for psychiatric disorders and based on 4 factors labeled anxiety, depression, somatic symptoms, and social dysfunction. The GHQ-28 was developed by Goldberg and Hillier in 1979 and is based on the original GHQ-60. The scores on each subscale were categorized as 0-6 as having no disorder, 7-11 as mild, 12-16 as moderate and 17-21 as severe disorders. At any scale, a score of 6 or higher and a total of 22 or higher indicated morbid symptoms (30). The validity and reliability of GHQ-28 were con rmed in Iran (31).

Corona Disease Anxiety
The Corona Disease Anxiety Scale (CDAS) was prepared to measure the anxiety caused by the outbreak of coronavirus. This tool had 2 subgroups and each question was ranked on a four-point Likert scale (0 = never, 1 = sometimes, 2 = most of the time, and 3 = always). The highest and lowest scores for respondents in this questionnaire are between 0 and 54. High scores on this questionnaire indicate higher levels of anxiety in individuals. Preliminary validity and reliability of CDAS were con rmed in Iran (32).
Marital Satisfaction ENRICH (Enriching and Nurturing Relationship Issues, Communication and Happiness) Marital Satisfaction Scale (EMS Scale) was used which is composed of 10 questions scoring a 5-point Likert-type. Total score ranges 10 to 50. Higher scores indicate higher marital satisfaction (33). The Persian version of the EMS Scale has been validated (34).

Statistical analysis
After completing the questionnaires by the participants, the data were analyzed using Statistical Package for Social Sciences (SPSS) software, version 22, by descriptive and analytical statistics. P < 0.05 was considered statistically signi cant. To calculate the sample size, the appropriate formula was used and the 95% con dence interval and the 80% power test were considered. Data was summarized as mean (SD) for continuous variables, or n (%) for discrete variables. To compare the mean mental health, anxiety, depression, and marital satisfaction in three groups, analysis of Variance (ANOVA) was used Post-hoc correction using Tuckey's.

Results
Of the 657 women who completed the questionnaires, 53 women were excluded due to either not meeting the inclusion criteria or incomplete lling of questionnaires. A total of 604 valid questionnaires were analyzed, including 200 pregnant women, 203 lactating women, and 201 non-pregnant/lactating women ( Figure 1).
The mean age of the participants was 31.01±5.92, the mean duration of married was 6.71± 5.03, and the mean number of children was 1.09±0.82. There were no signi cant differences in education level, duration of menstruation, duration of marriage, number of children, and history of COVID-19 (P > 0.05). Demographic characteristics of the three groups are shown in Table 1.
The results of table 2 show that there were statistically signi cant differences between the three groups in somatic symptoms, anxiety, social dysfunction, and total GHQ scores (P < 0.001).
Toki Post-hoc comparisons revealed signi cantly less total GHQ scores between control group with pregnant women

Marital satisfaction status
In table 4, Toki post hoc test revealed that the mean of marital satisfaction was signi cantly higher in control group compared with the pregnant (29.64±3.18 vs. 28.06±2.67, P < 0.001) and lactating women (29.64±3.18 vs. 28.74±3.58, P = 0.01). There were no signi cant differences between the lactating women and the pregnant women in the mean score of marital satisfaction (P > 0.05).

Discussion
In this article pregnant and lactating women are at higher risk for mental disorders during outbreaks of COVID-19. According to our results, the total scores of GHQ in pregnant and lactating women was higher than nonpregnant/lactating women and even almost all cases of moderate to severe levels of anxiety, social dysfunction, and physical symptoms were observed in these women. This is supported by the fact that emergency and con ict situations, natural disasters, extreme stress, and low social support can increase the risks associated with speci c mental health disorders during pregnancy and after childbirth (15), and so these women are at risk for mental disorders in the spread of infectious diseases (16).
Moghanibashi-Mansourieh. found that the level of anxiety in women was signi cantly higher than men in the COVID-19 outbreaks (35) and Lee DT et al. reported that the anxiety levels of pregnant women at the peak of the SARS outbreaks in Hong Kong were slightly higher than a comparative pre-SARS group (36). In the present study, both anxiety and COVID-19-related anxiety were measured, and the mean anxiety of pregnant and lactating women was higher than non-pregnant/lactating women. According to previous studies, the cause of increased anxiety may be due to issues related to pregnancy, lactating, or the additional burden of anxiety caused by the outbreaks of COVID-19 (14,15,17,18).
Lee DT et al. also reported that there was no statistically difference in the levels of depression between the pregnant women at the peak of the SARS and pre-SARS group. As in our research, there was no signi cant difference in depression between the three groups, which was different from previous research that depression symptoms existed among the general population during the COVID-19 outbreaks. Huang Y and Zhao N found that almost one in ve participants in the study had depressive symptoms (37).
Our results on depression among the three groups were possibly due to the high socioeconomic status, such as the large number of participants with education over 12 years and income above 3 million (Tomans) in our participants.
Pregnancy and childbirth are periods of life transition in which the quality of the relationship may play an important role (38). Bayrami M et al. reported that marital satisfaction was negatively associated with anxiety. The anxiety was stable in different circumstances and could have a signi cant negative effect on marital satisfaction (39). The outbreaks of COVID-19 can cause anxiety, which can affect marital satisfaction. According to the present study, the marital satisfaction of pregnant and lactating women was lower than non-pregnant/lactating women. Hence, both pregnant and lactating women are at higher risk for anxiety and low marital satisfaction within the COVID-19 outbreaks.
The limitation of this study is that participants must have the ability to use computers at least; otherwise they would not be able to participate in the study. Therefore, the results of this research cannot be generalized to all pregnant and lactating women. The strength of this research is that participants from a wide range of geographical and socioeconomic backgrounds were included.

Conclusion
In conclusion, our results showed that pregnant and lactating women are vulnerable to mental health problems and are more likely to experience anxiety and have less marital satisfaction during the outbreaks of COVID-19. Further research is warranted to explore the impact of COVID-19 outbreak on the mental health and marital satisfaction of pregnant and lactating women with consideration of socioeconomic status. The study was approved by the Ethics Committee of Tarbiat Modares University of Medical Sciences (IR.MODARES.REC.1399.004). All procedures were in accordance with the ethical standards of the Regional research committee and with the Declaration of Helsinki 1964 and its later amendments. After explaining the study's purposes, written consent assent were collected from all participants and women were informed that their participation were voluntary, con dential, and anonymous, and were apprised of their right to withdraw from the research at any time.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request

Competing interests
The authors declare no con ict of interest.