Investigating the Effect of COVID-19 on Spiritual Health and Stress of Pregnant Women


 Introduction: Stress is one of the effective factors in the occurrence of negative effects during pregnancy that can cause adverse outcomes such as preterm delivery and reduced intrauterine growth of the fetus in pregnant women. Therefore, one of the serious concerns during the COVID-19 Pandemic is the physical health and mental health of pregnant women. This study aimed to evaluate the physical health status with the spiritual and mental health of pregnant women during the COVID-19 Pandemic.Methods: The study is a descriptive study in 2019-2020 and the samples were randomly selected from all pregnant women who referred to hospitals and private maternity centers before and during the COVID-19 Pandemic and performed all pregnancy and fetal health tests. It was performed on 560 pregnant female samples. The mental status of pregnant women was assessed using the DASS Spiritual Health and Stress Questionnaire. Data analysis was performed using SPSS statistical software (version 24).Result: The results of this study showed that preterm birth, height, weight and head circumference of babies and lungs and respiratory status of children with mental health and stress levels of pregnant women during the corona is significant compared to the previous of corona (p<0.05).Conclusion: Increasing stress and decreasing the mental health of pregnant women during COVID-19 Pandemic can increase the influencing factors in preterm delivery and unhealthy birth.


Introduction:
In December 2019 release of a viral disease was reported in the city of Wuhan, China. The cause of this disease was a new and genetically modi ed virus from the family of coronaviruses called -SARS 2-CoV, which was named Covid-19 disease (1). The psychological effects of this viral disease on the mental health of people at different levels of society are of great importance (2). Some psychological disorders, including stress experienced by women during pregnancy, can have adverse effects on childbearing outcomes. Among the adverse consequences of preterm delivery and weight loss at birth is because preterm delivery is one of the undesirable consequences of increasing the mortality rate of unborn babies and pregnant women (3). At the beginning of 2020, many pregnant women due to epidemic COVID-19, in a state of quarantine exception to the living and the personal life and career and nances are changed and many of them due to fear and stress They have been quarantined in their homes for a long time due to infection and loss of fetus, and this can lead to affect women's emotional health. As depression and stress have been one of the symptoms of the prenatal period, but with the development of this viral disease, the adverse consequences of pregnant women and adverse infants were increased (4).
In recent years, most psychologists and specialists have emphasized the importance of spiritual health in the development and promotion of mental and emotional status of individuals and its necessity in individual and social life and consider it as one of the factors affecting the health of individuals. In de ning spiritual health, the World Health Organization considers it as one of the in uential dimensions of human life and the fourth basic dimension in promoting spirituality (5). In today's world, one of the newest dimensions of health, apart from physical and mental health, is spiritual health. All aspects of health are meaningful in the form of spiritual health and lead to an increase in the quality of life (6).
Spiritual health plays a very important role in determining the health status of people and causes symptoms such as depression, loneliness and meaninglessness in life. Spiritual health is one of the indicators related to stress relief and increasing the improvement score of a person's mental health (7).
One of the most important complications of preterm delivery in women is the birth of babies with inappropriate weight and outside the standard range. These babies suffer from unusual damage and unusual weight loss at birth and during their nal development (8,9). In developing countries and Iran, the prevalence of preterm labor is 25% and 34.9%, respectively (9). Pregnant women are exposed to stressful changes in the levels of their hormones, and these hormones cross the blood-brain barrier and affect the growth rate of the fetus and can harm the fetus and at birth or Growth weight or abnormal weight. Weight loss and sudden weight loss have reduced the safety of the baby's immune system and the release of neurotransmitters such as dopamine, serotonin, GABA and norepinephrine have also been reported in infants who have been stressed during the fetal period (10). One of the factors affecting the type of normal or premature birth in women is the amount of stress they receive during pregnancy and leads to disorders during and after childbirth in pregnant women such as depression and mood disorders and these effects on fetal health of infants (11), blood pressure(Chronic) (12), infections at the episiotomy site (13), increasing the likelihood of unplanned cesarean delivery. Therefore, due to the changes made during pregnancy, the need for psychological adjustment in women is essential (14). Stress is the most obvious sign in the behavior and clinical signs of pregnant women (15). Because pregnant women undergo many physical and psychological changes during pregnancy, their impact on different life stresses during this period increases (16). Pregnancy is one of the most stressful times for most women and is considered one of the most stressful times in a woman's life. The severity of stress in the last trimester is higher than in the rst 6 months of pregnancy. Therefore, during this period, the chances of developing depression and anxiety -fear and stress increase and most pregnant women experience these mood and mental disorders (17).
Pregnancy and childbirth is an important issue in women's lives, and since women are mental health guarantees the mental health of the whole family and the baby that is born. In this research, the effect of Coronavirus on the rate of precocious and early delivery and stress in pregnant women who referred to Isfahan medical centers was investigated.

Study population and design
In this descriptive research, 620 pregnant women were selected using cluster random sampling method.
The study population included pregnant women referring to Isfahan Private and Medical Hospital in 2019 and 2020. A total of 560 pregnant women had referred to these centers in Mani and a hospital in Isfahan for prenatal and delivery care. The sampling method was as follows: rst, 10 centers out of 15 health centers were randomly selected by a simple lottery. The sample size was calculated based on a preliminary study with a reliability coe cient Con dence 95% (α = 0.05) power of test 80% (β = 0.2) and the correlation coe cient formula was calculated. Questionnaires for people who could not read and complete the questionnaire were read and completed by health workers working in the centers. Not all people were eligible to participate in the study, and the study cost was considered for them, so that pregnant women were excluded from the study if they had a history of mental illness such as depression or inability to perform daily activities such as disability. In this study, three questionnaires of personal characteristics (age, level of education, occupation, gestational age, age of marriage), spiritual health and stress anxiety and depression DASS were used. To prevent interfering factors before completing the questionnaires removed the women that had, pregnant women with drug addiction, a history of heart disease and high-risk pregnancy, a history of visiting a psychiatrist or psychologist, and taking medication or hospitalization mental illness.

Palutzian and Ellison Mental Health Questionnaire
One of the related questionnaires for spiritual health is a 20-item questionnaire in which two dimensions of health are examined (18). 10 questions of it belong to the dimension of religious health and 10 other questions examine the existential health of the individual. Religious and existential health questions are placed one by one in the questionnaire, and religious health begins with the individual's questions. The nal score of this questionnaire is between20-120 and it has a 6-point Likert scale. The nal score of the questionnaire is divided into three distinct categories: 20-40, average 41-99 and high 120 − 100. This study has been studied by Farahani Nia in Iran (19). In this Seyedfatemi et al, validity spiritual health through credit Speci c content and reliability through Cronbach's alpha reliability coe cient was determined to be 82.0 (20).

General Self-E cacy Questionnaire
One of the effective questionnaires in the eld of self-e cacy is Sheerer Scale questionnaire (23). The Self-E cacy Questionnaire has 17 questions that are used as 5-point Likert and reverse (24) The highest and in fact the quorum for this questionnaire is 85 and the minimum is 17 Narrative in Iran. Its reliability was obtained by internal consistency and the new test of 0.83 (25).

Data analysis
The questionnaires were completed by pregnant women after explaining the objectives of the research and the satisfaction of the samples with the guidance of the questioner and in the form of a self-report.
Data were analyzed using SPSS software (Version 24) and analysis the variance. The signi cance level of this study was considered to be 0.05.

Results:
In this study, the selected age group with the highest percentage (41.78%) includes 25-30 years. Among the types of jobs in women, those who worked at home had the highest percentage (90.5%). In terms of education level, about half of the women had primary education. Most women in this study were in the last months of pregnancy and their average age at marriage was 25-30 years (52.4%).
Also In the results, the mean score of spiritual health of pregnant women 99.13 ± 14.21 compared to the total score of 560 shows that about 43.3% of women had a normal with average score level of spiritual health and about 10.3% shows increasing level of spiritual health and the others appeared with a lowering level of spiritual health.. Also, the results of the study showed that the average score of religious health (51.3 ± 7.75) is higher than existential health (47.8 ± 7.40). The relationship between contextual and demographic variables and spiritual health was studied unilaterally and the results are listed in Table  (Table 1).
Based on Scheffe statistical method, the score of spiritual health in terms of occupation, a month of pregnancy, and age of marriage was a signi cant difference. The use of the Scheffe test showed that there was a signi cant difference in spiritual health with housewives, self-employed people (p = 0.05). Also, spiritual health in people with a marriage age of more than 30 years was signi cantly different from that of people less than 25 years of age was higher (p < 0.001).
The result shows that the mean self-e cacy score in pregnant women 63.7 ± 8.84., 50.5%. the ranking of the subjects had low self-e cacy, 45% had moderate self-e cacy and 4.50% had high self-e cacy. The effect of demographic variables on self-e cacy was investigated using a one-way analysis of variance (Table 1).  This result showed that self-e cacy score was signi cantly different according to age, time of marriage, and month of pregnancy. The use of the Scheffe test showed that the self-e cacy score in women over 30 years of age was signi cantly higher than women under 25 years of age (p = 0.024). Also, the rate of self-e cacy in the second trimester of pregnancy was signi cantly higher. Signi cance was higher than self-e cacy in the rst quarter (p = 0.014).
The independent and dependent variables in this study are spiritual health and self-e cacy, respectively. Because of the heterogeneity between the independent and dependent variables, the preferred statistical method is simple linear regression. Kolmogorov test showed that the dependent variable was normal (p = 0.046) ( Table 2).
The relative frequency of stress and its related components in pregnant women is shown in Table 3. Of 560 pregnant women, 35.31% were in the upper range, 44.64% were women in the moderate stress range, 25% were in the high range, and during the coronavirus epidemic. Between stress and level of education (P < 0.05) employment (P < 0.05) signi cant difference was achieved, while between stress and socioeconomic status (P = 1.03) and age (P = 0.85) was not Signi cant. religious and spiritual duties such as prayer is effective in increasing the level of self-belief and selfcon dence and can even increase the level of self-e cacy (32). Also, the present study showed that spiritual health can predict self-e cacy. In this study, spiritual health and its dimensions were able to predict self-e cacy and the existing health had the highest effect on predicting self-e cacy of pregnant women. This result is consistent with the results of the Syed Imam study on the health status of students, which showed that it predicts spiritual health, self-e cacy, and self-esteem (33).
the de nition of Pregnancy Expressed as a stressful period time for women, and caused the fear, stress among pregnant women and increased fear and anxiety due to acute respiratory disease Quid 19 reduces spiritual health, so this study with the present results Has consistent (34). Complications of labor are different for each woman, but in most of them, there was a high degree of stress and anxiety, leading to the birth of babies with special conditions like premature birth, low birth weight, nausea, and vomiting (27,35). To con rm the results of the present study, we can refer a study that conducted by Durankuş in 2020 and shown the Covid-19 increases rate of depression, stress in pregnant women, so the amount of stress and depression During the COVID − 19 increased (35,36).
Facing a coronavirus epidemic has affected all members of society, especially pregnant women, stress and psychological problems and prevents the birth of healthy babies because most mothers experience premature birth due to quarantine conditions and increased stress, and their children. They are not natural. Finally, with increasing stress, the spiritual health of pregnant women decreases even in the religious and Islamic population of Iran, and this study needs to be reviewed worldwide to eliminate cultural in uences as an intervening factor.

Conclusion:
The aim of research represent majority of pregnant women in the time of COVID-19 epidemic had little spiritual health, and on the other hand, spiritual health and its dimensions were able to introduce selfe cacy as a known factor for behavior. Therefore, it is necessary to study more about the effects of spiritual health on the self-e cacy of pregnant women around the world to examine the effectiveness of the role of self-e cacy and spiritual health in stress changes in the COVID 19 viral crisis. All authors agree to publish the article.
Availability of data and material: The data that support the analysis of this study (Analysis codes and outputs) are available on request from the corresponding author (M.Nazari). The raw data are not publicly available due to institutional restrictions. Funding: This research did not receive any speci c grant from funding agencies in the public, commercial.
Competing interests: The authors stated that they had no known nancial interests or competitive personal relationships that may appear to affect the work reported in this article. There is no con ict of material or spiritual interest between the paper authors.