This study describes the health-related behavior changes and psychological status of pregnant women after the peak of COVID-19 outbreak in China. An earlier study in China found that most pregnant women took protective measures including wearing masks, washing hands frequently and staying at home [12]. Our study got similar results. In addition, pregnant women washed hands with soap or hand sanitizer more frequently and went out less often than before the epidemic. However, there was no significant change in the frequency of spitting on the ground and bathing during the COVID-19 outbreak compared with before the outbreak. The possible reason is that most (92.9%) pregnant women did not spit on the ground. Therefore, the frequency of spitting on the ground didn’t decline significantly. As for bathing, as a habitual behavior, it's hard to change [23]. Another reason may be that we had assumed that pregnant women would change clothes and shower after contact with others. In this study, the frequency of pregnant women going out every week was low during the outbreak (median 2.0, IQR 0.0–4.0). This had little influence on the frequency of bathing among pregnant women who bathed almost every day.
Earlier studies reported that pregnant women from different countries experienced different levels of anxiety or depression during the early or peak period of COVID-19 [5–8, 12]. In Wuhan, 24.5% of pregnant women reported self-rated anxiety, compared with 10.4% of that in Chongqing, China [6]. The rate of anxiety (assessed by state–trait anxiety inventory) was 38.2% among pregnant women in Italy [8]. The rate of depression (assessed by EPDS) was 35.4% among Turkish pregnant women and 29.6% among Chinese women in the third trimester of pregnancy [5, 7]. Although the peak of the epidemic in China has passed, the psychological condition of pregnant women does not seem to improve, as we found that 73 (64.6%), 66 (58.4%) and 62 (54.9%) pregnant women had anxiety, depression and health risk stress, respectively. This may be due to the uncertainty of the disease in the absence of an effective vaccine. The news of domestic sporadic cases and imported cases from abroad may cause fear and panic among pregnant women.
Previous study found higher rates of anxiety among pregnant women in Wuhan than Chongqing during the COVID-19 outbreak [6]. However, we found no significant association between cities (Wuhan and other cities) and different psychological status (anxiety, depression and health risk stress). The possible reason is that the COVID-19 outbreak in Wuhan was under control. Pregnant women in Wuhan were not as feared and scared as they used to be. Another reason is the presence of imported cases in other provinces and cities such as Beijing, Guangdong and Tianjing in China. This can cause some anxiety, fear and panic in the absence of a well-organized approach to preventing and controlling imports from abroad at beginning. Due to the publicity of the government and the media, only three (2.7%) pregnant women had little knowledge about COVID-19, and four (3.5%) had little knowledge about maternal and child protection. This suggests that pregnant women were well informed about COVID-19 and maternal and child protection. We found that pregnant women who knew some-what about COVID-19 were more likely to have health risk stress than those who had a lot of knowledge. Pregnant women who knew some-what about maternal and child protection were more likely to develop depression and health risk stress than those who knew a lot. In addition, pregnant women with higher anxiety, depression or stress perceived a higher likelihood of infection. So pregnant women's understanding of COVID-19 and maternal and child protection and their perception of the likelihood of infection should be considered in psychological intervention. We also need to pay attention to specific demographic characteristics (household income, gestational age and pregnancy complications) of pregnant women, as they can affect psychology.
A study from Hong Kong found that general population who felt emotionally distressed were more likely to avoid going out than others in the initial stage of H1N1 outbreak [24]. However, we found that the frequency of going out was positively correlated with anxiety and stress. One possible explanation is that pregnant women with higher anxiety and stress tended to go out to relax after staying at home for a long time. Another possibility is that we observed an opposite relationship, where the more often they went out, the more pregnant women worried about getting infected, leading to higher anxiety and stress. More research is needed to clarify the relationship between health-related behavior and psychology among pregnant women during the COVID-19 outbreak. Pregnant women who had antenatal check-ups were more likely to be depressed than those who had not. This is probably because pregnant women were worried about getting infected during antenatal visits [25]. A study in Hong Kong found that 66.7% pregnant women feared going to the hospital for a prenatal check-up during the 2003 severe acute respiratory syndrome (SARS) outbreak [26]. As a result, in our study, some (12.4%) pregnant women did not have antenatal visits and some (29.2%) pregnant women did not have them on time. It’s normal that 88 (77.9%) pregnant women sought help when they felt panic and anxiety during the COVID-19 outbreak. However, those who sought help were more likely to be anxious and depressed than those who did not. The possible explanation is that few pregnant women sought help from psychological workers in our study (those who can provide professional psychological screening and intervention), left unresolved psychological problems after help seeking. Another possible explanation is that pregnant women may be more concerned about how to protect themselves and their babies rather than psychological problems in the process of seeking help. As a result, the psychological status of pregnant women has not received good attention. Therefore, screening for anxiety, depression and stress and professional psychological interventions whether online or offline are needed.
There are several limitations to this study. First, we did not examine a history of mental health problems in pregnant women, which may influence anxiety, depression and stress scores. Second, this study was a cross-sectional study in nature, which makes it impossible to determine the causal relationship between some variables. Finally, we did not conduct multivariate logistic regression analysis to adjust for confounders because the sample of outcome variables was small and the relationships between some variables were so complex to determine. The results of this study should be interpreted with caution due to false-positive or false-negative results from small sample and univariate logistic regression. More research is needed to establish structural equation models to determine the path relationship between pregnant women’s characteristics, health-related behavior and psychology.