Keywords
COVID-19 - pandemic - pregnant - depression - sexual function
Palavras-chave
Covid-19 - pandemia - grávida - depressão - função sexual
Introduction
Caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), coronavirus
disease 2019 (COVID-19) began with the first suspicious cases in November 2019 in
Wuhan, Hubei, China, in late December. After that, the disease shortly spread throughout
the world, in about three months. It was declared a pandemic by the World Health Organization
(WHO) on March 12, 2020, and the first case in Turkey was reported on March 11, 2020.[1]
[2] The entire world is facing an unprecedented crisis due to the rapidness, depth,
and scope of the pandemic. The physical, mental, and social well-being of people is
being adversely affected throughout the pandemic, and the national and international
measures taken against it have directly or indirectly affected people's economic well-being.
Movement restrictions, one of the measures to slow down the spread of the pandemic,
negatively affected the supply of labor. As has been the case in the global market,
Turkey has also experienced an increase in the unemployment rate and decreased incomes.[3] A decrease in people's economic welfare levels in society can increase the rates
of depression.[4]
Previous studies[5]
[6] have revealed that the tendency to develop depression among females is higher than
among males. Some studies[6]
[7] performed during the pandemic found that females were affected more adversely compared
with the males. The mother might experience emotional fluctuations during pregnancy
due to the anxiety she feels for both herself and the fetus.[8] The physiological and psychosocial changes that occur during pregnancy increase
the tendency of developing depression and anxiety. In this regard, pregnant and new
mothers are included in the vulnerable and high-risk group for depression.[9]
[10]
The female sexual response cycle can be divided into four phases: baseline, arousal
(excitement), orgasm, and resolution. Regarding these phases, women might experience
various sexual dysfunctions, such as lack of sexual drive and arousal, and inability
to orgasm during sexual activity. It is an underestimated problem with a general prevalence
between 20% and 50%.[11] On the other hand, it has been demonstrated that a significant decrease in sexual
activities occurs with pregnancy. Physical discomfort, fear of injuring the fetus,
loss of sexual drive, physical awkwardness, painful sexual activity, and perceived
lack of attraction are among the reported causes of this decrease in sexual activity
during pregnancy.[12]
The present research aimed to investigate the depression and sexual functions of pregnant
and non-pregnant women throughout the COVID-19 pandemic.
Methods
The present is a cross-sectional trial conducted from May to August, 2020 with 96
healthy pregnant and 92 nonpregnant women, totalling a sample of 188 women. Most of
the pregnant and non-pregnant women whom we invited to the study did not want to participate;
they wanted to be in the hospital for a shorter time because they were afraid of contact
transmission by the doctor. In total, 188 healthy women aged between 18 and 45 years
who sought care at the Gynecology and Obstetrics Outpatient Clinic of a hospital in
Turkey, and who did not have any known disorder, had not received medication for chronic
conditions, and voluntarily agreed to participate in our study were included. Pregnant
women who had fetal or maternal problems during their pregnancy, women who had a medical
history of psychiatric or sexual dysfunction, and participants who submitted incomplete
questionnaires were excluded from the study. The participants read and signed the
informed consent form; after that, we collected sociodemographic data from them, and
applied the Beck Depression Inventory (BDI) and Arizona Sexual Experience Scale (ASEX).
Approval of the Ethics Committee was obtained (2020/514/176/9), with the project name
of 2020–05–07T14_43_09, from the Ministry of Health of the Republic of Turkey to conduct
the relevant scientific research.
Sociodemographic data, such as age, level of schooling, occupational status, and obstetric
status was obtained from the patients. They were asked whether they were pregnant
or not, and, if they were, their gestational week was requested, and they were divided
into three groups based on the trimester: first trimester (up until the 14th gestational
week), second trimester (14th to 28th gestational weeks), and third trimester (28th
to 42th gestational weeks) groups. Based on data from May 2020 from the Turkish Statistical
Institute, those with a total family monthly income below the hunger limit (2,438
Turkish Lira [TL]) are considered the lower-income class, those below the poverty
line (7,942 TL), the middle-income class, and those with a higher income (> 7,942
TL), the upper-income class. Regarding loss of income during the pandemic, the participants
were examined in 3 groups:, those who had no income loss, those who lost up to 50%
of their income, and those who lost more than 50% of their income.
The BDI was developed to measure the risk of depression, the level of the depressive
symptoms, and the fluctuation in the severity of depression among adults. It is a
self-administered questionnaire developed by Beck et al.[13], which consists of 21 items. The items of the scale are scored from 0 and 3 points.
Higher scores indicate greater symptom severity. In those diagnosed with depression,
scores of between 0 and 13 indicate minimal depression, from 14 to 19, mild depression,
from 20 to 28, moderate depression and, from 29 to 63, severe depression.[14] The validity and reliability study of the Turkish adaptation of the questionnaire
was performed by Hisli.[15]
The Arizona Sexual Experience Scale (ASEX), which has been developed by McGahuey et
al.[16] to briefly and efficiently screen and identify the problems experienced by patients
in their sexual life, is a five-item rating scale that measures sexual drive, arousal,
vaginal lubrication/penile erection, ability to have an orgasm, and satisfaction from
orgasm; and it also has separate questionnaires specific to male and female subjects.
We used the female form (questionnaire detailed to female patients) in the present
study. The total score ranges from 5 to 30, and lower scores manifest that the sexual
response is strong, easy, and satisfying, whereas higher scores display sexual dysfunction.
The higher the scores, the more sexual dysfunction there is.[16] Based on the ASEX scores, the participants were included in the healthy group (scores
from 0 to 10), the group with moderate sexual disorder (scores from 11 to 17), and
the group with severe sexual disorder (scores ≥ 18). The validity and reliability
of the Turkish adaptation of the ASEX have been tested among patients with renal failure.[17]
For the categorical values, p-values were calculated using the Chi-squared test. For the continuous variables,
the p-values were calculated using the Mann Whitney U test the and Kruskall Wallis test.
Multivariable logistic regressions were used to calculate odds ratios (ORs) and 95%
confidence intervals (95%CIs) for the associations between sexual dysfunction and
depressive symptoms. Potential a priori confounders (such as, age, occupational status,
and parity) were included in the models. All statistical analyses were performed using
The Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows,
IBM Corp., Armonk, NY, United States) software, version 25.0.
Results
The mean age of the sample was 30.1 ± 6.4 years. The demographics of the participants
are presented in [Table 1].
Table 1
Demographics of the study participants
|
Age (years)
|
|
Mean (standard deviation): 30.1 (6.4)
|
Median (range): 29.0 (18.0–45.0)
|
|
|
n
|
%
|
|
Level of schooling
|
Primary school graduate
|
23
|
12.2%
|
|
High school graduate
|
68
|
36.2%
|
|
University graduate or higher
|
97
|
51.6%
|
|
Occupational status
|
Unemployed
|
100
|
53.2%
|
|
Working in the public sector
|
57
|
30.3%
|
|
Working in the private sector
|
31
|
16.5%
|
|
Level of income
|
Low
|
17
|
9.0%
|
|
Medium
|
110
|
58.5%
|
|
High
|
61
|
32.4%
|
|
Pregnancy
|
Absent
|
92
|
48.9%
|
|
Present
|
96
|
51.1%
|
|
Trimester of pregnancy
|
First
|
20
|
20.8%
|
|
Second
|
58
|
60.4%
|
|
Third
|
18
|
18.8%
|
|
Parity
|
Nulliparous
|
70
|
37.2%
|
|
Multiparous
|
118
|
62.8%
|
|
Type of delivery
|
Nulliparous
|
70
|
37.2%
|
|
Cesarean
|
69
|
36.7%
|
|
Vaginal
|
49
|
26.1%
|
|
Total
|
|
188
|
100.0%
|
In the univariate analysis of the factors affecting the presence of depression among
the participants, severe depression was significantly more prevalent among those who
were unemployed compared with the other groups. Besides, as the level of income decreases,
the percentage of mild or moderate depression increases significantly (p = 0.046) ([Table 2]).
Table 2
Factors impacting depression among the study participants
|
Healthy
|
Mildly depressed
|
Moderately/severely depressed
|
|
|
n
|
%
|
n
|
%
|
n
|
%
|
p-value
|
|
Level of schooling
|
Primary school graduate
|
5
|
21.7%
|
8
|
34.8%
|
10
|
43.5%
|
0.115
|
|
High school graduate
|
21
|
30.9%
|
33
|
48.5%
|
14
|
20.6%
|
|
University graduate or higher
|
37
|
38.1%
|
41
|
42.3%
|
19
|
19.6%
|
|
Occupational status
|
Unemployed
|
25
|
25.0%
|
45
|
45.0%
|
30
|
30.0%
|
0.003
|
|
Working in the public sector
|
30
|
52.6%
|
20
|
35.1%
|
7
|
12.3%
|
|
Working in the private sector
|
8
|
25.8%
|
17
|
54.8%
|
6
|
19.4%
|
|
Level of income
|
Low
|
3
|
17.6%
|
7
|
41.2%
|
7
|
41.2%
|
0.046
|
|
Medium
|
34
|
30.9%
|
47
|
42.7%
|
29
|
26.4%
|
|
High
|
26
|
42.6%
|
28
|
45.9%
|
7
|
11.5%
|
|
Loss of income during the pandemic
|
No
|
46
|
40.7%
|
46
|
40.7%
|
21
|
18.6%
|
0.124
|
|
≤ 50%
|
9
|
22.5%
|
19
|
47.5%
|
12
|
30.0%
|
|
> 50%
|
8
|
22.9%
|
17
|
48.6%
|
10
|
28.6%
|
|
Pregnancy
|
Absent
|
29
|
31.5%
|
41
|
44.6%
|
22
|
23.9%
|
0.846
|
|
Present
|
34
|
35.4%
|
41
|
42.7%
|
21
|
21.9%
|
|
Trimester of pregnancy
|
First
|
10
|
50.0%
|
7
|
35.0%
|
3
|
15.0%
|
0.097
|
|
Second
|
22
|
37.9%
|
25
|
43.1%
|
11
|
19.0%
|
|
Third
|
2
|
11.1%
|
9
|
50.0%
|
7
|
38.9%
|
|
Parity
|
Nulliparous
|
24
|
34.3%
|
31
|
44.3%
|
15
|
21.4%
|
0.936
|
|
Multiparous
|
39
|
33.1%
|
51
|
43.2%
|
28
|
23.7%
|
|
Type of delivery
|
Cesarean
|
24
|
34.8%
|
29
|
42.0%
|
16
|
23.2%
|
0.986
|
|
Vaginal
|
15
|
30.6%
|
22
|
44.9%
|
12
|
24.5%
|
|
Relative infected with COVID-19
|
No
|
56
|
36.8%
|
65
|
42.8%
|
31
|
20.4%
|
0.087
|
|
Yes
|
7
|
19.4%
|
17
|
47.2%
|
12
|
33.3%
|
In the univariate analysis of the BDI scores of the participants, they were significantly
higher among those who were unemployed (mean = 13.8) compared with those working in
the public sector (mean = 9.5) (p < 0.001). We also found that, as the level of economic income decreases, depression
scores increase significantly (p = 0.009). The BDI score (mean = 13.9) was significantly higher among the participants
who lost their income during the pandemic compared with those who did not experienced
income loss (mean = 11.4) (p = 0.001). Furthermore, the BDI scores (mean = 14.0) of the patients whose relatives
were diagnosed with COVID-19 was significantly higher than the scores of those whose
relatives were not diagnosed (p = 0.013) ([Table 3]).
Table 3
Factors impacting the score of Beck Depression Inventory
|
Mean
|
standard deviation
|
Median
|
First quartile
|
Third quartile
|
p-value
|
|
Level of schooling
|
Primary school graduate
|
15.4
|
7.8
|
14.0
|
10.0
|
19.0
|
0.080
|
|
High school graduate
|
12.3
|
5.4
|
12.0
|
8.0
|
16.0
|
|
University graduate or higher
|
11.6
|
6.2
|
11.0
|
8.0
|
15.0
|
|
Occupational status
|
Unemployed
|
13.8
|
6.2
|
13.0
|
9.5
|
18.0
|
< 0.001
|
|
Working in the public sector
|
9.5
|
6.0
|
9.0
|
5.0
|
12.0
|
|
Working in the private sector
|
12.9
|
5.2
|
13.0
|
8.0
|
16.0
|
|
Level of income
|
Low
|
15.3
|
4.8
|
17.0
|
13.0
|
18.0
|
0.009
|
|
Medium
|
12.7
|
6.6
|
12.0
|
8.0
|
17.0
|
|
High
|
10.9
|
5.6
|
11.0
|
7.0
|
14.0
|
|
Loss of income during the pandemic
|
No
|
11.4
|
6.4
|
11.0
|
7.0
|
14.0
|
0.001
|
|
Yes
|
13.9
|
5.8
|
14.0
|
10.0
|
18.0
|
|
Pregnancy
|
Absent
|
12.5
|
6.2
|
12.0
|
8.0
|
17.0
|
0.389
|
|
Present
|
12.1
|
6.3
|
11.0
|
7.5
|
16.0
|
|
Trimester of pregnancy
|
First
|
11.1
|
6.4
|
10.0
|
7.0
|
15.0
|
0.081
|
|
Second
|
11.9
|
6.7
|
10.0
|
7.0
|
14.0
|
|
Third
|
14.1
|
4.7
|
14.5
|
11.0
|
17.0
|
|
Parity
|
Nulliparous
|
12.4
|
6.3
|
11.0
|
8.0
|
14.0
|
0.654
|
|
Multiparous
|
12.3
|
6.2
|
12.0
|
8.0
|
17.0
|
|
Type of delivery
|
Cesarean
|
12.0
|
5.8
|
13.0
|
8.0
|
16.0
|
0.888
|
|
Vaginal
|
12.7
|
6.8
|
12.0
|
8.0
|
18.0
|
|
Relative infected with COVID-19
|
No
|
11.9
|
6.4
|
11.0
|
8.0
|
16.0
|
0.013
|
|
Yes
|
14.0
|
5.3
|
15.0
|
11.5
|
18.0
|
We found that the rate of severe sexual disorder among pregnant women was significantly
higher than that of the non-pregnant women (p = 0.006). On the other hand, the percentage of moderate sexual dysfunction was significantly
higher among multiparous women (p = 0.016). When the participants were categorized based on their depression status,
moderate sexual dysfunction was determined to be high in patients with mild depressive
symptoms, whereas the rate of severe sexual dysfunction was found to be high in those
with severe depressive symptoms (p = 0.008) ([Table 4]).
Table 4
Factors impacting sexual dysfunction
|
Normal
|
Moderate sexual dysfunction
|
Severe sexual dysfunction
|
|
|
n
|
%
|
n
|
%
|
n
|
%
|
p-value
|
|
Level of schooling
|
Primary school graduate
|
1
|
4.3%
|
14
|
60.9%
|
8
|
34.8%
|
0.145
|
|
High school graduate
|
14
|
20.6%
|
40
|
58.8%
|
14
|
20.6%
|
|
University graduate or higher
|
24
|
24.7%
|
57
|
58.8%
|
16
|
16.5%
|
|
Occupational status
|
Unemployed
|
14
|
14.0%
|
62
|
62.0%
|
24
|
24.0%
|
0.088
|
|
Working in the public sector
|
14
|
24.6%
|
34
|
59.6%
|
9
|
15.8%
|
|
Working in the private sector
|
11
|
35.5%
|
15
|
48.4%
|
5
|
16.1%
|
|
Level of income
|
Low
|
0
|
0.0%
|
12
|
70.6%
|
5
|
29.4%
|
0.101
|
|
Medium
|
21
|
19.1%
|
66
|
60.0%
|
23
|
20.9%
|
|
High
|
18
|
29.5%
|
33
|
54.1%
|
10
|
16.4%
|
|
Loss of income during the pandemic
|
No
|
29
|
25.7%
|
63
|
55.8%
|
21
|
18.6%
|
0.123
|
|
Yes
|
10
|
13.3%
|
48
|
64.0%
|
17
|
22.7%
|
|
Pregnancy
|
Absent
|
23
|
25.0%
|
59
|
64.1%
|
10
|
10.9%
|
0.006
|
|
Present
|
16
|
16.7%
|
52
|
54.2%
|
28
|
29.2%
|
|
Trimester of pregnancy
|
First
|
4
|
20.0%
|
12
|
60.0%
|
4
|
20.0%
|
0.579
|
|
Second
|
11
|
19.0%
|
29
|
50.0%
|
18
|
31.0%
|
|
Third
|
1
|
5.6%
|
11
|
61.1%
|
6
|
33.3%
|
|
Parity
|
Nulliparous
|
22
|
31.4%
|
34
|
48.6%
|
14
|
20.0%
|
0.016
|
|
Multiparous
|
17
|
14.4%
|
77
|
65.3%
|
24
|
20.3%
|
|
Type of delivery
|
Cesarean
|
14
|
20.3%
|
43
|
62.3%
|
12
|
17.4%
|
0.018
|
|
Vaginal
|
3
|
6.1%
|
34
|
69.4%
|
12
|
24.5%
|
|
Relative infected with COVID-19
|
No
|
32
|
21.1%
|
88
|
57.9%
|
32
|
21.1%
|
0.783
|
|
Yes
|
7
|
19.4%
|
23
|
63.9%
|
6
|
16.7%
|
|
Depression
|
Normal
|
20
|
31.7%
|
29
|
46.0%
|
14
|
22.2%
|
0.008
|
|
Mildly depressed
|
15
|
18.3%
|
56
|
68.3%
|
11
|
13.4%
|
|
Moderately/severely depressed
|
4
|
9.3%
|
26
|
60.5%
|
13
|
30.2%
|
According to the univariate analysis, ASEX score decreases significantly as the level
of schooling increases. Moreover, the ASEX score was higher among those who were unemployed.
As the level of economic income decreases, the ASEX score increases significantly.
We found that as the loss of income rose during the COVID-19 pandemic, the ASEX score
also rose significantly. In addition to that, as depressive symptoms increased, the
ASEX score increased as well (p = 0.005) ([Table 5]).
Table 5
Factors impacting the Arizona Sexual Experience Scale
|
Arizona Sexual Experience Scale
|
|
|
Mean
|
Standard deviation
|
Median
|
First quartile
|
Third quartile
|
p-value
|
|
Level of schooling
|
Primary school graduate
|
16.2
|
3.3
|
15.0
|
14.0
|
19.0
|
0.034
|
|
High school graduate
|
14.4
|
4.1
|
14.0
|
12.0
|
17.0
|
|
University graduate or higher
|
13.8
|
3.6
|
14.0
|
11.0
|
17.0
|
|
Occupational status
|
Unemployed
|
14.9
|
3.6
|
15.0
|
13.0
|
17.0
|
0.032
|
|
Working in the public sector
|
13.8
|
3.9
|
13.0
|
11.0
|
15.0
|
|
Working in the private sector
|
13.4
|
4.1
|
14.0
|
10.0
|
16.0
|
|
Level of income
|
Low
|
15.9
|
2.6
|
16.0
|
15.0
|
18.0
|
0.040
|
|
Medium
|
14.4
|
3.9
|
14.0
|
12.0
|
17.0
|
|
High
|
13.7
|
3.9
|
14.0
|
10.0
|
15.0
|
|
Loss of income during pandemic
|
No
|
13.8
|
3.8
|
14.0
|
10.0
|
16.0
|
0.019
|
|
≤ 50%
|
14.6
|
4.1
|
15.0
|
13.0
|
16.0
|
|
> 50%
|
15.7
|
3.3
|
16.0
|
13.0
|
18.0
|
|
Pregnancy
|
Absent
|
13.3
|
3.3
|
13.0
|
10.5
|
15.0
|
< 0.001
|
|
Present
|
15.2
|
4.0
|
15.0
|
13.0
|
18.0
|
|
Trimester of pregnancy
|
First
|
14.6
|
3.8
|
15.0
|
13.0
|
17.0
|
0.260
|
|
Second
|
15.1
|
4.4
|
15.0
|
12.0
|
18.0
|
|
Third
|
16.4
|
2.7
|
17.0
|
15.0
|
19.0
|
|
Parity
|
Nulliparous
|
13.8
|
4.1
|
14.0
|
10.0
|
17.0
|
0.064
|
|
Multiparous
|
14.6
|
3.6
|
15.0
|
13.0
|
17.0
|
|
Type of delivery
|
Nulliparous
|
13.8
|
4.1
|
14.0
|
10.0
|
17.0
|
0.098
|
|
Cesarean
|
14.3
|
4.0
|
15.0
|
12.0
|
17.0
|
|
Vaginal
|
15.0
|
3.1
|
15.0
|
13.0
|
17.0
|
|
Relative infected with COVID-19
|
No
|
14.3
|
3.8
|
14.0
|
12.0
|
17.0
|
0.888
|
|
Yes
|
14.2
|
3.9
|
14.0
|
12.0
|
16.0
|
|
Depression
|
Normal
|
13.7
|
4.4
|
14.0
|
10.0
|
17.0
|
0.005
|
|
Mildly depressed
|
14.0
|
3.1
|
14.0
|
12.0
|
15.0
|
|
Moderately/severely depressed
|
15.8
|
3.8
|
16.0
|
14.0
|
18.0
|
When the factors affecting sexual dysfunction in women are analyzed by the multivariate
analysis, odds ratio increase was found 1.18 times (95% CI 1.07–1.31), corresponding
to each unit increase of age. Compared with those without depressive symptoms, the
risk of sexual dysfunction in mildly-depressed patients increased 4.31 times (95%CI:
1.57 to 11.82), while this rate was of 5.57 (95%CI: 1.42 to 21.81) among participants
with moderate/severe depression. The risk of sexual dysfunction increased 6.40 times
(95%CI: 2.09 to 19.54) among unemployed patients compared with those employed in the
private sector. Moreover, there was an increase of 6.20 in the OR (95% CI 2.15–17.90)
among pregnant women compared with non-pregnant women ([Table 6]).
Table 6
Multivariate analysis of the factors impacting sexual dysfunction
|
B
|
SE
|
Wald test
|
p
-value
|
Odds Ratio
|
95% confidence interval
|
|
Lower
|
Upper
|
|
Age (years)
|
0.173
|
0.051
|
11.598
|
0.001
|
1.189
|
1.076
|
1.313
|
|
Healthy
|
|
|
10.153
|
0.006
|
|
|
|
|
Mildly depressed
|
1.462
|
0.514
|
8.084
|
0.004
|
4.317
|
1.575
|
11.829
|
|
Moderately/severely depressed
|
1.718
|
0.696
|
6.089
|
0.014
|
5.573
|
1.424
|
21.812
|
|
Working in the private sector
|
|
|
10.696
|
0.005
|
|
|
|
|
Unemployed
|
1.857
|
0.569
|
10.634
|
0.001
|
6.402
|
2.098
|
19.543
|
|
Working in the public sector
|
1.217
|
0.635
|
3.670
|
0.055
|
3.377
|
.972
|
11.731
|
|
Pregnant
|
1.826
|
0.540
|
11.421
|
0.001
|
6.209
|
2.153
|
17.905
|
|
Multiparous
|
0.267
|
0.539
|
0.245
|
0.620
|
1.306
|
0.454
|
3.758
|
|
Loss of income
|
1.040
|
0.545
|
3.647
|
0.056
|
2.830
|
0.973
|
8.230
|
B = value; SE = standard error.
When the correlation analysis was performed between the ASEX and BDI scores regarding
the pregnancy status, a slightly positive significant correlation was found among
pregnant women (r = 0.365; p < 0.001).
Discussion
The expectant mother may experience emotional fluctuations throughout pregnancy because
she is concerned about herself and the fetus.[18] Depression, which may be experienced during pregnancy, may lead to maternal and
fetal complications.[8] The stress experienced throughout the pregnancy might trigger preterm labor through
the activation of the pituitary and adrenal axis, and is also a risk factor for gestational
hypertension and preeclampsia.[8]
[19] Previous researches have reported that the prevalence of depression during pregnancy
ranges from 12% to 36%.[20] In the present study, we found that 42.7% of pregnant women had mild symptoms of
depression throughout the pandemic, whereas 21% had moderetely-severe symptoms of
depression. Similarly, depression rates in non-pregnant women were found to be significantly
higher than studies conducted before the pandemic. In studies of depression in female
university students in Turkey prevalence of ranges from 9.2% to 35.2%, in other countries
between 18.5% and 52.6% (14a–14c).[6]
[21]
[22] In the present study, we found that 44.6% of non-pregnant women had mild symptoms
of depression throughout the pandemic, whereas 22% had moderate/severe symptoms. A
study[23] performed in Turkey during the pandemic reported that it has a considerable impact
on the levels of depression and anxiety of pregnant women. In a multi-center cross-sectional
study[24] performed in China comparing the mental state of pregnant women before and after
the declaration of the COVID-19 pandemic, the authors reported that pregnant women
who were examined after the announcement of the COVID-19 outbreak had significantly
higher levels of anxiety and symptoms of depression.
Previous studies[25]
[26] have suggested that individuals who are in the lower socioeconomic class have a
higher rate of mental disorders such as depression compared with individuals in middle
and upper socioeconomic classes. Upon reviewing the literature, we could not detect
one study that revealed a correlation between depression and parameters such as economic
status and income loss during the COVID-19 pandemic. In the present study, the depression
scores were significantly higher among the group with lower economic status. Likewise,
the BDI score was significantly higher among patients who lost their income during
the pandemic. The depression scores were significantly higher among females whose
relatives have been infected with COVID-19.
The present study has demonstrated that the depression scores increased among women
during the pandemic, which is in line with reports in the literature.[15]
[16] In the present study, we found that pregnant and non-pregnant women are adversely
affected in a similar manner; on the other hand, the study suggests that circumstances
such as being in the low-income class, experiencing loss of income, and having relatives
infected with COVID-19 may increase the risk of developing depression.
Sexual life is one of the factors that affect the general health status and quality
of life of women. Sexual dysfunction is a multifactorial problem influenced by various
biological, psychological, and environmental factors.[27] It has been suggested[28] that sexual dysfunction is a common problem that increases with age and impacts
30% to 50% of women. Women who have an ASEX score ≥ 11 are considered to have sexual
dysfunction. In a study[29] comparing pregnant and non-pregnant women in Turkey before the pandemic, the authors
found high ASEX scores in 55.6% of pregnant women and in 23.2% of non-pregnant women.
In the present study the rate of sexual dysfunction during the pandemic was of 83.3%
among pregnant women, and of 75% among non-pregnant women. This situation indicated
that the sexual lives of all women were negatively affected throughout the pandemic.
A significantly higher rate of sexual dysfunction was also detected among pregnant
women in the present study, and the OR was 6.2, which is in line with previous studies.[29]
[30]
It is well documented that the level of socioeconomic well-being impacts sexuality.
Previous studies[31]
[32] have reported that sexual dysfunction was more prevalent among women with a lower
economic status. Similarly, in the present study, sexual dysfunction was significantly
higher among women in the lower-income class and among those who lost their income
during the pandemic. The risk of sexual dysfunction among unemployed women is 6.40
times higher than that of employed women. One study[33] demonstrated that sexual dysfunction is less common among women with higher levels
of schooling. Likewise, the results of the present study support the aforementioned
finding as well the fact that, as the level of schooling increases, the prevalence
of sexual dysfunction decreases significantly.
Previous studies[34]
[35]
[36]
[37] have suggested that the previous number of births and the type of delivery do not
impact the sexual function. In the present study, similar results were found when
the ASEX scores were analyzed.
It has been claimed[38] that people under restriction have a high tendency to develop depression and anxiety,
and that sexual intercourse while under restriction is a protective factor against
depression. One study[39] found that several women who were using short-acting reversible contraception (SARC)
discontinued their contraceptive method during the pandemic but continued to engage
in sexual activity and had unplanned pregnancies. The BDI and ASEX scores were also
observed in parallel in the present study ([Tables 3],[4]), and The BDI scores were significantly higher among women with sexual dysfunction.
This study has some limitations; Firstly, it is a cross-sectional trial and the long-term
effects are unknown. Secondly, the study compared slightly different women in the
same period, not different periods when the same women were pregnant and not pregnant.
Finally, the negative impact of the pandemic detected among the participants may have
been milder than the impact felt by women in other parts of Turkey, since the district
where the present study was performed was considered a low-risk area for infection
by SARS-CoV2.
Conclusion
In the present study, women who lost their income during the pandemic had higher rates
of depression and sexual dysfunction. Upon comparing the pregnant and nonpregnant
women, we found that the rates of depression were similarly higher in both groups
than the before pandemic, whereas the rate of sexual dysfunction was 6.2 times (95%CI:
2.1 to 17.9) higher among pregnant women. Low-income families and women have an increased
risk of experiencing depression and sexual dysfunction in times of global crises,
such as a pandemic.
