The number of patients and suspicious are increasing and the uncertainty and low predictability of pandemic threaten people’s mental health (17). To our knowledge, our study was among one of the first studies to investigate the impact of the COVID-19 pandemic on the depression, anxiety, sexual function, and QoL of pregnant and lactating women and compare the results with non-pregnant /lactating women in Iran.
Depression and anxiety
In the results of this study, pregnant and lactating women got significantly lower scores in both dimensions of mental status (depression and anxiety), compared to the non-pregnant / non-lactating women.
These results seem to be consistent with Wu et al. research, which found the impact of COVID-19 awareness on the increasing prevalence of prenatal depression (PND). The trend of PND prevalence increased with the number of death and newly-diagnosed patients, lack of access to the features of the disease, fear of infection, and vertical transmission from mother to fetus (18).
Due to the high prevalence of Covid-19, the WHO has proposed quarantine to reduce human-to-human transmission (19). Many symptoms of mental distress such as depression, stress, irritability, and insomnia in those who had been quarantined, have been reported higher. Quarantine stressors include longer duration of quarantine, fear of infection, loss of normal life routine, reduced social activity, and physical contact with others, having inadequate basic supplies, lack of sufficient information, and clear guidelines on actions to take, and serious socioeconomic problems (20).
Previous epidemic (SARS) experiments have shown that pregnant women suffer from high levels of anxiety, especially those who are more emotionally vulnerable (21).
Stress and anxiety suppress the immune system and make people susceptible to infectious diseases (22) and various studies have reported an association between mental morbidity during pregnancy and adverse outcomes of pregnancy such as low birth weight and preterm labor (23). In addition, pregnancy and postpartum depression are both associated with shorter breastfeeding duration, likewise, mother's anxiety is associated with breastfeeding difficulties, shorter breastfeeding intention, and duration of breastfeeding (24). The cumulative effect of the mental burden imposed on society by COVID-19 along with pregnancy and lactating as a mentally sensitive period may be a possible explanation for these results.
Given the devastating effects of anxiety and depression on the immune system, pregnancy, and lactating, these results emphasize the importance of mental health care for pregnant and lactating mothers in outbreak duration.
Sexual function status
Sexual function as a physical, emotional, and mental state is an essential part of each human being’s personality and the cornerstone of a couple's relationship; it also has a significant impact on QoL (25). The vast majority of studies showed that sexual function decreases significantly during pregnancy, and this decline can be continued for the first 3–6 months after delivery (26). The present study also demonstrated that there was a significant FSD in pregnant and lactating women.
Yuksel et al. (27) compared the frequency of sexual intercourse, desire for pregnancy, and FSFI scores among women during the COVID-19 pandemic with 6–12 months prior to the pandemic. They reported higher sexual desire and frequency of sexual intercourse whereas the lower quality of sexual life during the COVID-19 pandemic. The study also found a significant reduction in the number of women planning to become pregnant, which could result in fears about its possible effects on the fetus, difficult access to the health system, and economic problems. However, high levels of chronic stress in other disasters have led to a decrease in sexual desire and intercourse (28).
Although not much data is available, unemployment due to quarantine, anxiety about job security, worry about personal and family health, and the ability to have access to medical care can affect sexual desire howsoever some people may resort to sex for comfort or a temporary distraction (29). Anxiety disorder and depression symptoms caused by “hypochondriac concerns” (worry about being infected) (30) and the proven effect of anxiety and depression on sexual function (31) may explain increased sexual dysfunction in COVID-19 outbreak.
The results of this study did not show a significant difference in FSD between pregnant and lactating women. Both pregnancy and lactation can affect sexual function through physical changes (including fatigue, back pain, dyspareunia, urinary tract infections, and vaginitis), hormonal changes (changed levels of estrogen, progesterone, and prolactin), and psychogenic factors (such as the anxiety of delivery and motherhood, relationship, lack of self-esteem, sexual guilt, and specific concerns about body image and general health status) (32).
According to low estrogen and progesterone levels and high levels of prolactin during lactating (33) and increasing blood vessels in the vagina and decreased sexual arousal in pregnancy that can lead to dryness(34); contrary to our expectations, this study found more prevalence of lubrication dysfunction in non-pregnant /lactating women.
Given to considerable impacts of pregnancy (35) and lactation (36) on sexual activity by the many significant physical and mental changes, pregnant and lactating women are more prone to the effectiveness of the mental impact of COVID-19 and sexual dysfunction.
Quality of life status
QoL is defined as people's perception of their position in life within their cultural and value contexts, which relates to their goals, expectations, standards, and concerns (37).
In terms of the factors associated with QoL, an increased rate of depression, anxiety, sleep disorders, and experience of the life-threatening events were associated with a poor QoL during pregnancy (38). The results of this study, therefore, indicate significantly lower mental components of QoL during the pandemic in pregnant and lactating women (P˂0.001). Possible reasons are the economic effects of quarantine and epidemic, the unpredictable future, and the fear of the infant's health. Our study results were consistent with the findings reported by Lau et al, who investigated mental health and QoL in Hong Kong residents during the SARS epidemic (39).
Han Xiao reported the effect of anxiety and stress of COVID-19 quarantine on sleep quality such as difficulty falling asleep, or wake up easily (40) also, Shao-YuTsai demonstrated a high prevalence of sleep disturbances in pregnant women(41). There are several possible explanations for lower QoL in pregnant women during COVID-19; one of them is the cumulative effects of these factors and the importance of quality of sleep in QoL.
The results of this study indicated a lower score of physical QoL throughout pregnancy than lactating and non-pregnant / non-lactating women., particularly related to decreased physical activity and physical symptoms such as nausea and vomiting, epigastralgia, reflux, shortness of breath, dizziness, back pain, and sleep problems (42).
One of the limitations of this study was the lack of accurate information about the mental and sexual profile of participants before the pandemic. Another one was that the questionnaires were filled online and if participants needed additional information about the questions, no professional was available.
Based on our knowledge, there are reasonably good understanding of the correlation between pregnancy, postpartum period and depression, but there are almost nothing about the relationship between COVID-19 pandemic and mental health, sexual function, and QoL. Since the COVID-19 pandemic is still ongoing, these findings need to be confirmed and investigated in future larger population studies.