A Survey Among Italian Pregnant Women and New-mothers During the COVID-19 Pandemic Lockdown.


 In response to the COVID-19 pandemics, drastic measures for social distancing have been introduced also in Italy. The purpose of this study was to describe some aspects of lifestyle, access to health services, and mental wellness of Italian pregnant women and new-mothers during the lockdown. We carried out a web-based survey to assess how pregnant women and new-mothers were coping with the lockdown. Expected outcomes were categorized in different analysis domains: psychological well-being and support, physical exercise, dietary habits, access to care, delivery and obstetric care, neonatal care and breastfeeding.We included 742 respondents (response rate 86.2%), 603 were pregnant (81.3%) and 139 (18.7%) had delivered during lockdown. We found a high score for anxiety and depression in 62.7% of pregnant women and 61.9% of new-mothers. During the lockdown, 61.9% of pregnant women reduced their physical exercise, and 79.8% reported to eat in a healthier way. 94.2% of new-mothers reported to have breastfed their babies during hospital staying. Regarding the impact of restrictive measures on breastfeeding, no impact was reported by 56.1% of new-mothers, a negative impact by 36.7%.The higher prevalence of anxiety and depressive symptoms in pregnant women and new-mothers should be a public health issue. Clinicians might also consider to recommend and encourage “home” physical exercise. On the other hand, most women improved their approach towards healthy eating during the lockdown and a very high breastfeeding rate was reported soon after birth: these data are an interesting starting point to develop new strategies for public health.


Introduction
Since severe acute respiratory syndrome SARS-CoV-2 started to spread across several countries, the World Health Organization declared that the outbreak was a public health emergency of international concern (1).
Based on the Chinese experience (2), starting from March 9th, 2020, drastic measures have been introduced also in Italy: citizens are banned from leaving their home unless for daily needs that cannot be postponed. As a consequence, a sudden and radical change in habits and lifestyles of the whole population, a minimization of socialization and changes in both interpersonal relationships and organization of work occurred.
Hospital activity has radically changed: many Departments were closed in order to create COVID-19 dedicated hospital wards, the rest of the clinical activity was downsized and contacts with patients were reduced to the minimum. Measures such as re-adaptation of care priorities and several restrictions will presumably lead to changes in the health of the population in the coming months or years.
There are still many unanswered questions regarding the effect of lockdown measures on pregnant women (3) (4). Healthcare workers are facing an important challenge in terms of reshaping obstetric care in order to avoid unnecessary exposure to patients, without renouncing the required attention. Although obstetric units have not diminished their working activity, there have been changes in territorial and hospital care. Some activities whose usefulness is established by evidence, have undergone through major downsizing. The pre-birth courses have been o cially stopped; some screening tests have been performed much less frequently, due to reduced patient access to the tests, or due to di culties in providing the services. Family members and partners presence during important moments, such as ultrasound screens and hospitalization, has been reduced for safety reasons.
Most of the pregnant women and new-mothers found themselves unable to leave their home, often with other children to look after, not able to count on any domestic help (5). On the other hand, some women may have welcomed the chance of working from home or in some cases counting on a larger presence of their partner.
It can be assumed that these changes may have an in uence on pregnancy, puerperium and newborn management that obstetricians should consider (4). While published studies on the possible effects of COVID-19 disease in pregnant women and infants are increasing (6), there are only few studies (7) (8) (9) dealing with the psychological effect of the pandemic on pregnant women. To the best of our knowledge, there are still no studies in literature about how mothers are coping with the lockdown and highlighting the needs of this population group in that period.
The purpose of this study is to describe some aspects of lifestyle, access to health services and mental wellness of Italian pregnant women and new-mothers during the lockdown.

Study Design, setting and participants
We carried out a cross-sectional survey by using an anonymous online questionnaire. The survey addressed both pregnant women and women who gave birth during the lockdown. As the Italian government recommended to minimize face-to-face interaction, the questionnaire was web based; individuals were offered the opportunity to participate through social media (pages of Facebook and Instagram dedicated to new-mothers and pregnant women) and through newspapers sections for women issues.
Individuals were directed via an electronic link to an online survey platform. Duplicate entries were avoided by asking people to provide their e-mail address at the end of the survey; duplicate entries having the same e-mail address were eliminated before analysis and the rst entry was kept. The survey was not displayed a second time once the responder had lled it in, but the link to pass it on to others was available. Therefore, snowball sampling technique, where existing study subjects recruit future subjects among their acquaintances, was also used. The survey period lasted for 4 weeks through the lockdown period, from April 9th, 2020 to May 3rd, 2020.

Ethical considerations
The survey was preceded by a fact sheet including information on what the research was about, the reason for conducting the research, how the data will be used, how privacy of data will be maintained, information in case the respondents changed their mind during the survey, along with contact details for further information. Afterward, the consent to participate was required to proceed with the survey. The participation in the survey was voluntary and anonymous. Approval was obtained from the local Ethical Committee (Comitato Etico Interaziendale Novara CE 71/20), which conformed to the principles embodied in the Declaration of Helsinki.

Variables and data sources
Expected outcomes of the baseline analysis concerned different topics that could be in uenced by the lockdown measures, and were categorized in different analysis domains, related to pregnancy and puerperium.
About pregnancy the analyzed domains were 1-psychological well-being and support; 2-physical exercise; 3-dietary habits; 4-access to care. About puerperium the analyzed domains were 5-psychological well-being and support; 6-delivery and obstetric care; 7-neonatal care and breastfeeding.
Due to the lack of validated questionnaires about this topic, authors reviewed previous and current surveys (10) on the impacts of outbreaks and included additional questions related to pregnancy and birth (11) (12) (13). To investigate the psychological impact we used the Patient Health Questionnaire for Depression and Anxiety (the PHQ-4) (14). The questionnaire was tested in a sample of voluntary pregnant women and new-mothers, with different characteristics (age, education, parity) who reviewed the questionnaire individually and provided verbal feedback, and it was also submitted to a panel of experts (psychologist, midwife, epidemiologist), for content validity and construct coherence. Completion time was 15 minutes.
The survey consisted of a common part including sociodemographic and psychological questions, addressing both pregnant women and new-mothers, followed by a speci c part dedicated either to pregnant women or women who gave birth during the lockdown, each divided into sub-sections of questions, addressing the different analysis domains.

Statistical analysis
We analyzed frequency distributions of variables separately for pregnant women and new-mothers, calculated means and standard deviations for continue variables. T-test was used to study the differences between categories in the continuous variable (expressed as mean and SD), while for the categorical variables (expressed as number and percentage of the total) the reference test was chi-square (χ2). Level of signi cance was set with p < 0.05. Poisson regression multivariate models were used to calculate prevalence ratios and relative 95% con dence intervals. Statistical analysis was performed using Stata Statistical Software: Release 15. StataCorp LLC.

Results
We received responses from 861 women (Fig. 1). Eight (0.9%) women did not give their consent to participate, while 111 (12.9%) were excluded because either not pregnant or not having given birth during the restrictive measures. We included 742 respondents from 107 different cities in Italy, who had completed the questionnaires (completion rate: 96%). Overall, 603 respondents were pregnant (81.3%) and 139 (18.7%) respondents had delivered in the lockdown period.
Sociodemographic, living, housing and psychological characteristics of pregnant women and new-mothers Data are reported in Table 1. The overall response rate for these items was > 99%. Changes in the life of pregnant women during the lockdown  Regarding the access to health-care services, only 25.1% of women in our sample was attending an online pre-birth course and 11.9% of them avoided to go to an ob-gyn emergency room because of the fear of contagion, preferring a phone contact with a gynecologist or a midwife. 26.4% of our sample skipped some planned visit and 18.7% of them skipped planned exams or vaccines.
The experience of delivering during the lockdown for new-mothers Table 3 describes the experience of delivery and of baby management during the lockdown. The overall response rate for these items was > 99%. The mean gestational age at the time of delivery was 39.4 ± 1.3 weeks (range 36-42 weeks). 84.2% of the partners had the possibility to assist during labor. 75.3% of women declared they were afraid of giving birth during the COVID-19 pandemic and they reported that the reality was as they expected in 50.8% of cases, better than expected in 36.2%. In our sample, only 3 women (2.2%) had a con rmed SARS-CoV-2 infection: all of them were separated from their newborns maintaining the possibility to feed them with expressed breast milk.
Adjusted analysis for pregnant women Table 4 shows χ2 and prevalence across independent variables and three crucial outcomes in the pregnant women group: PH4 score from moderate to severe, di culties in healthy eating and reduction in physical exercise. The prevalence of women with anxiety or depressive moderate to severe score was signi cantly higher in the group of women with a lower educational attainment and not satis ed with their economic resources and house. Additionally, it was also signi cantly lower in women who could count on the support of their partner. Finally, there is a trend showing a higher score in the rst trimester.
While for most women restrictions gave them the chance to eat healthier, 20.2% of women reported di culties in healthy eating.
Likewise, a lower educational attainment, unsatisfaction with economic resources and house, and the lack of partner supporting are signi cantly associated to more di culties in healthy eating during the lockdown. Furthermore, di culties in healthy eating also directly correlated with having contacts with other people during the lockdown, having children at home and being in the third trimester of pregnancy.
Lastly, during the lockdown there was a signi cant reduction in physical activity, but this data is transversal to all the respondents and there are no signi cant differences between groups, except for two variables: women who had reduced the activity are those who during the lockdown had less free time than before, and who were in the rst trimester.

Discussion
This study describes how pregnant women managed to cope with the lockdown in Italy. We found a high score for anxiety and depression, despite it cannot be compared to the same score on the same population before the pandemic. Our survey also suggests that the lockdown made it more di cult for pregnant women to exercise for 150 minutes per week in accordance with the ACOG guidelines (15), and we can assume that a reduction in physical exercise will affect the quality of life of pregnant women, as demonstrated in previous studies (16). On the other side it seems that staying at home facilitated the approach to healthy eating, for the group with the partner's support and a better socio-economic status. This is an interesting data that deserves more investigations and it is a starting point to develop new strategies for public health.
Among women who gave birth during the pandemic, although three-fourths of the respondents declared to be afraid of giving birth during such a complex period, the overall experience was as expected or better than expected for 87% of the population. Despite more than half of the new-mothers reported a negative in uence on the baby's management and more than one-third of them reported a negative in uence on their breastfeeding experience, the breastfeeding rate is consistent or even better than the ones before the pandemic (17), suggesting a slight discrepancy between expectations/perceptions and actual facts, probably due to the anxiety and depression characteristics found in our sample. More than half of new-mothers received no support for breastfeeding after hospital discharge; however almost all of the respondents have continued to breastfed their babies when discharged at home. It could be inferred that, in the impossibility to rely on external support, new-mothers have empowered their internal resources with satisfying results.
The high level of anxiety and depression is consistent with other studies (8) (9). The prevalence in the rst trimester is con rmed (9) while, differently from another study (8) in our survey this data was not correlated with age, primiparity and area of living. The correlation with economic di culties and education is consistent with the literature (16), and some studies suggest that COVID 19 pandemic may even worsen the social inequalities (18). Regarding the fact that a reduction of face to face visits could have occurred to women during the restrictions; a recent survey shows that patients are actually open to alternative models of prenatal care, including remote monitoring (19). Future survey could be done in the same population in order to nd out if some changes are considered positively. According to a Cochrane review (20) communicating results of medical investigations by mobile phone messaging may make little or no difference to women's anxiety overall or in women with positive test results, but may reduce anxiety in women with negative test results. We cannot exclude that this method will be more largely implemented in future times, after the COVID-19 emergency and the lesson it gave us about face-to-face contact.
A higher prevalence of anxiety and depressive symptoms in pregnant and new-mother populations should be a public health issue, and screening for perinatal depression and anxiety should be considered during a pandemic. Under the circumstances of social distancing and isolation, psychological hotlines and online counseling would be a smart strategy to manage perinatal mental illness. The same strategy would be useful to help new-mothers with the baby management. Healthcare professionals, should also ensure patients feel supported by continuing their routine prenatal care through tele-medicine visits (21). Clinicians might also consider recommending and encouraging "home" physical exercise, especially in women in the rst trimester, who might be the most worried about the sudden change of their lives.
Isolation, increased stress, and sedentary lifestyle in pregnancy can also lead to adverse pregnancy outcomes, such as preterm birth, gestational diabetes and low birth weight (22)(23). This survey is also a baseline questionnaire for those women who gave consent to be contacted, and they will be followed up as a cohort in order to identify possible complications. In a further part of our project, we are going to describe in greater detail how the lockdown in uenced neonatal outcomes.
The rst limitation of the present study is related to the non-random sampling: women are enrolled by newspaper advertisements, social media and the snow-ball method; the completeness checks process was not exhaustive. A second limitation is the lack of validated questionnaire designed to capture such a delicate and unique moment. Third, the assessment of depressive and anxiety symptoms through a short scale which relied on a self-reported measure and does not provide a diagnosis. Although these limits, this is the rst study to assess some aspects of the lifestyle of pregnant women and new-mothers during the lockdown in Italy. Besides, the web-based method is a strength because it gave us the opportunity to interview a geographically dislocated population during a short time in the lock-down period.
Given the unicity of this SAR-CoV2 pandemic we tried to give an overview of the experience of Italian pregnant women and new-mothers during the lockdown. Next steps will be to incorporate those ndings in political choices. The WHO Executive Board recognizes the need to include women in decision making for outbreak preparedness and response, however there is still inadequate women's representation in national and global COVID-19 policy spaces (24). It is also important that health professionals commit themselves to help pregnant women and new-mothers to overcome these di cult times.

Declarations
Ethics approval and consent to participate: the consent to participate was required and he participation in the survey was voluntary and anonymous. Approval was obtained from the local Ethical Committee (Comitato Etico Interaziendale Novara CE 71/20), which conformed to the principles embodied in the Declaration of Helsinki.

Consent for publication: Not applicable
Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to privacy reasons but are available from the corresponding author on reasonable request.

Figure 1
Supplementary Files This is a list of supplementary les associated with this preprint. Click to download. Surveyinenglish.docx