Keywords
pregnancy - maternal anxiety - childbirth - postpartum - questionnaires - breastfeeding
- coronavirus disease 2019 - pandemic
Palavras-chave
gravidez - ansiedade materna - parto - pós-parto - questionários - amamentação - infecção
por coronavírus 2019 - pandemia
Introduction
Coronavirus disease 2019 (COVID-19) is a respiratory infection caused by the SARS-CoV-2
coronavirus, which is potentially serious and highly transmissible.[1] The first case was identified in December 2019 in the city of Wuhan, China,[2] and the infection quickly reached global proportions and was declared a pandemic
by the World Health Organization (WHO) on March 11, 2020.[3]
In Brazil, the first case of COVID-19 was detected on February 26, 2020, in São Paulo,
and due to the rapid growth in the number of occurrences in Brazil, on May 22 the
WHO declared South America as the epicenter of the pandemic. Brazil is among the countries
with the highest number of cases and deaths from COVID-19. The mortality of hospitalized
patients is high even in those < 60 years old, mainly due to regional disparities
and delays within the health system.[4]
Since the beginning of the pandemic, it has been observed that the elderly and people
with comorbidities are vulnerable to the severe form of COVID-19.[1] However, other groups have been associated with an increased severity of the disease,
including pregnant and postpartum women. Even among healthy pregnant women without
disease or any identified previous medical morbidity, COVID-19 can progress to severe
maternal morbidity and maternal death. In Brazil, COVID-19 has been associated with
increased maternal deaths, with a substantial proportion of these deaths occurring
without intensive care or respiratory support, suggesting delays in the provision
of health care. Takemoto et al.[5] found a case fatality rate of 12.7% among women with severe acute respiratory syndrome
due to COVID-19 during pregnancy and the postpartum period, using the national surveillance
system data on severe respiratory diseases.
In this critical scenario, a national online survey applied to the Brazilian population
during the pandemic found a high prevalence of depression (61%) and anxiety (44%).[6] Pregnant women may be vulnerable to anxiety due to increased concerns about childbirth
and the risks of vertical transmission. The effects of maternal infection on the fetus
and on the newborn are a source of concern and insecurity,[7] since COVID-19 during pregnancy is associated with an increased risk of adverse
maternal and perinatal outcomes.[8]
Results from the main study showed the impact of the COVID-19 pandemic on maternal
anxiety in Brazil.[9] Our study found moderate or severe anxiety in 23.4% of the women at the end of pregnancy.
The present secondary analysis addressed a subgroup of interviewed women who had no
comorbidity in pregnancy and childbirth. The aim was to verify the presence of maternal
anxiety in pregnant women without medical or obstetrical comorbidities in the context
of the COVID-19 outbreak and to analyze the association with maternal knowledge and
concerns about the pandemic.
Methods
A multicenter cross-sectional survey design including two questionnaires was performed
with data collected in 10 cities in Brazil. This is a secondary data analysis from
a larger study on anxiety during pregnancy. The study protocol was approved by the
Brazilian National Ethics Committee – CONEP (CAAE N° 31190120.6.1001.5505) and by
each local Research Ethics Committee where the data was collected. A written informed
consent form was signed by all included participants.
Women who delivered in the 10 public university hospitals were recruited from June
1, 2020, to August 31, 2020. Enrolment took place for a period of 60 consecutive days
at each center. All hospitals were linked to a federal or state public university
located in 10 cities: Manaus, state of Amazonas, Natal, state of Rio Grande do Norte,
Teresina, state of Piaui, São Paulo, state of São Paulo, Campinas, state of São Paulo,
Botucatu, state of São Paulo, Florianópolis, state of Santa Catarina, Porto Alegre,
state of Rio Grande do Sul, Campo Grande, state of Mato Grosso do Sul, and Brasília,
Federal District. Each university hospital had a local coordinator and trained medical
residents who were involved in applying the questionnaires.
For the present analysis, we considered postpartum women without medical or obstetrical
comorbidities> 18 years old; childbirth birth > 36 weeks of gestation; single and
alive newborn without malformations; no clinical suspicion or current diagnosis of
COVID-19; absence of psychiatric or mental disorder; and in good clinical condition.
The women were interviewed after childbirth and before hospital discharge. They were
asked to complete a sociodemographic questionnaire with questions that included maternal
age, parity, educational level, marital status, habits (smoking and consumption of
alcohol and illicit drugs), companionship during labor, gestational age at birth,
mode of delivery, birthweight, 5-minute Apgar score, history of COVID-19 during pregnancy, and history of COVID-19
in the family.
A face-to-face interview was conducted using a questionnaire with statements addressing
their knowledge and concerns about the COVID-19 pandemic, including information received
on prenatal care and instructions for childbirth and the postpartum, including breastfeeding.
This questionnaire comprised four domains: general knowledge and preventive care (4
items), prenatal concerns (4 items), cautions and fears during childbirth (5 items),
care and concerns about the newborn (5 items). Each item received a 5-point Likert
response ranging from 1 to 5 (strongly disagree, partially agree, indifferent, partially
agree, and fully agree). This questionnaire was specifically designed for the present
study.
The Beck Anxiety Inventory (BAI) was used to measure maternal anxiety. The questions
were answered following instructions to report symptoms of the last 7 days before
delivery. The BAI consists of a 21-item self-reported questionnaire for assessing
anxiety level. Each item describes a common symptom of anxiety and is rated on a 4-point
Likert scale ranging from 0 (not at all) to 3 (severe). The respondent was asked to
rate each symptom and then the total score was calculated (0–63). A high overall score
indicates a high level of anxiety. Anxiety levels are defined according to the total
score as follows: minimal anxiety (0–7), mild anxiety (8–15), moderate anxiety (16–25),
and severe anxiety (26–63).[10] A validated Brazilian Portuguese version of the BAI was used in the present study.[11]
Data were analyzed using MedCalc Statistical Software version 19.5.3 (MedCalc Software
Ltd, Ostend, Belgium). Descriptive statistics are presented as mean and standard deviation
(SD), median (IQR), or frequency and percentage (%). The associations of categorical
variables with binary outcomes were analyzed using the chi-squared test or the Fisher
exact test when appropriate. The Mann-Whitney U test was applied to continuous variables
with nonparametric distribution. The analyses were adjusted using logistic regression
for potential confounders: maternal age, nulliparity, race, educational level, marital
status, religious belief, smoking, alcohol consumption, and geographical location.
Correlation analysis was performed by the Spearman rank test and multiple regression
with enter procedure was used to identify independent variables correlated with the
BAI total score. Statistical significance was set at p < 0.05.
Results
During the 3-month period of the present study, 1,683 eligible women were invited
to participate in the study and 21 refused. Out of 1,662 women interviewed, 763 were
included in the present subanalysis since they did not have any disease or medical
comorbidity. Characteristics of the studied population and the overall results of
the BAI score are shown in [Table 1]. Most women were non-white and living with a partner. The BAI total score in late
pregnancy indicates that 16.1% presented moderate and 11.5% severe anxiety.
Table 1
Sociodemographic and obstetric characteristics, perinatal outcomes, and maternal anxiety
assessed by the Beck Anxiety Inventory (BAI) in pregnant women without medical or
obstetrical comorbidities during the COVID-19 outbreak in Brazil (n = 763)
|
Characteristics
|
Results
|
|
Maternal age, years old, mean, SD
|
27.1
|
(6.3)
|
|
Parity 0
|
311
|
40.8
|
|
Maternal race
|
|
White
|
233
|
30.5%
|
|
Mixed
|
443
|
58.1%
|
|
Black
|
74
|
9.7%
|
|
Asian or Brazilian Indian
|
13
|
1.7%
|
|
Cohabiting / married
|
667
|
87.4%
|
|
Educational level
|
|
Incomplete elementary school
|
4
|
0.5%
|
|
Elementary school
|
186
|
24.4%
|
|
High school
|
455
|
59.6%
|
|
College/University
|
118
|
15.5%
|
|
Religion
|
|
Evangelical
|
276
|
36.2%
|
|
Catholic
|
263
|
34.5%
|
|
Others
|
36
|
4.7%
|
|
Without religious belief
|
188
|
24.6%
|
|
Smoking
|
36
|
4.7%
|
|
Alcohol consumption
|
26
|
3.4%
|
|
Illicit drugs consumption
|
5
|
0.7%
|
|
Mode of delivery
|
|
Vaginal
|
451
|
59.1%
|
|
Cesarean
|
298
|
39.1%
|
|
Forceps / vacuum
|
14
|
1.9%
|
|
Companionship in labor
|
648
|
84.9%
|
|
Gestational age at birth, weeks, mean, SD
|
39.3
|
(1.2)
|
|
Birth weight, g, mean, SD
|
|
Low birthweight (< 2,500g)
|
28
|
3.7%
|
|
Macrosomia (> 4,000g)
|
63
|
8.3%
|
|
5-minute Apgar < 7
|
19
|
2.5%
|
|
COVID-19 during pregnancy
|
13
|
1.7%
|
|
COVID-19 in the family
|
31
|
4.1%
|
|
Maternal anxiety
|
|
Minimal
|
344
|
45.1%
|
|
Mild
|
208
|
27.3%
|
|
Moderate
|
123
|
16.1%
|
|
Severe
|
88
|
11.5%
|
|
BAI, total score
|
|
mean, SD
|
11.4
|
(10.5)
|
|
median (95%CI)
|
8.0
|
(8.0–9.0)
|
Abbreviations: BAI, Beck Anxiety Inventory; CI, confidence interval; SD, standard
deviation.
In the period of the present study, maternal anxiety according to each geographic
region is presented in [Table 2]. The BAI total score was significantly higher in women interviewed in the Central
West, in the South and in the Southeast than those in the North and in the Northeast
regions. The Northeast exhibited the lowest prevalence of maternal anxiety of all
regions. The Central West region had the highest proportion of moderate or severe
maternal anxiety.
Table 2
Maternal anxiety of pregnant women without medical or obstetrical comorbidities according
to geographic regions during the COVID-19 outbreak in Brazil
|
Total
|
Geographic region
|
|
Central West
|
North
|
Northeast
|
South
|
Southeast
|
|
(n = 150)
|
(n = 161)
|
(n = 106)
|
(n = 181)
|
(n = 165)
|
|
Maternal anxiety (BAI)
|
|
Minimal (0–7)
|
344
|
(45,1%)
|
63
|
(42.0)
|
82
|
(50.9)
|
61
|
(57.5)
|
75
|
(41.4)
|
63
|
(38.2)
|
|
Mild (8–15)
|
208
|
(27,3%)
|
41
|
(27.3)
|
43
|
(26.7)
|
25
|
(23.6)
|
48
|
(26.5)
|
51
|
(30.9)
|
|
Moderate (16–25)
|
123
|
(16,1%)
|
29
|
(19.3)
|
20
|
(12.4)
|
12
|
(11.3)
|
34
|
(18.8)
|
28
|
(17.0)
|
|
Severe (26–63)
|
88
|
(11,5%)
|
17
|
(11.3)
|
16
|
(9.9)
|
8
|
(7.5)
|
24
|
(13.3)
|
23
|
(13.9)
|
|
BAI score
|
|
Mean (SD)
|
11.4
|
(10.5)
|
12.1
|
(10.4)
|
10.2
|
(11.6)
|
8.4
|
(8.4)
|
12.4
|
(10.7)
|
12.6
|
(10.3)
|
|
Median (95%CI)*
|
8.0
|
(8.0–9.0)
|
10.0
|
(7.5–11.5)
|
5.0
|
(4.6–9.0)
|
7.0
|
(5.0–8.0)
|
10.0
|
(8.0–12.0)
|
10.0
|
(8.0–12.0)
|
Abbreviations: BAI, Beck Anxiety Inventory; CI, confidence interval; SD, standard
deviation.
* Kruskal-Wallis test p <0.001. Post-hoc analysis (Conover): Central West different from North and Northeast,
p < 0.05; North different from Central West, South, and Southeast, p < 0.05; Northeast different from Central West, South, and Southeast, p < 0.05; South different from North and Northeast, p < 0.05; Southeast different from North and Northeast, p < 0.05.
The crude and adjusted analysis for confounding factors of moderate or severe maternal
anxiety is presented in [Table 3]. The results showed the variable 'cohabiting with a partner' (adjusted odds ratio
[aOR]: 0.46. 95% confidence interval [CI]: 0.29–0.73) as a protective factor for maternal
anxiety and 'high school educational level' (aOR: 1.58; 95%CI: 1.04–2.40) as an independent
factor significantly associated with moderate or severe maternal anxiety at the end
of pregnancy.
Table 3
Characteristics of women and geographic region in Brazil according to moderate or
severe maternal anxiety as assessed by the Beck Anxiety Inventory during the COVID-19
outbreak
|
Characteristic
|
Maternal anxiety
|
|
|
Minimum or mild
|
Moderate or severe (n = 211)
|
p-value
a
|
aOR (95%CI)b
|
p-value
b
|
|
(n = 552)
|
|
Age, years old, median, AVR
|
26 (385.9)
|
26 (371.7)
|
0.426
|
–
|
0.896
|
|
Parity 0
|
212 (38.4)
|
99 (46.9)
|
0.032
|
–
|
0.133
|
|
Maternal race
|
|
White
|
154 (27.9)
|
79 (37.4) 33.9
|
0.011c
|
–
|
0.137
|
|
Nonwhite
|
398 (72.1)
|
132 (62.6) 24.9
|
|
|
|
|
Cohabiting / married
|
495 (89.7)
|
172 (81.5)
|
0.002
|
0.46 (0.29–0.73)
|
0.001
|
|
Educational level
|
|
High school
|
305 (55.3)
|
140 (66.4)
|
0.007
|
1.58 (1.04–2.40)
|
0.030
|
|
College/University
|
89 (16.1)
|
29 (24.6)
|
0.484
|
–
|
0.985
|
|
No religious belief
|
136 (24.6)
|
52 (24.6)
|
0.998
|
–
|
0.430
|
|
Smoking
|
21 (3.8)
|
15 (7.1)
|
0.054
|
–
|
0.154
|
|
Alcohol consumption
|
17 (3.1)
|
9 (4.3)
|
0.420
|
–
|
0.290
|
|
COVID-19 during pregnancy
|
8 (1.4)
|
5 (2.4)
|
0.380
|
–
|
0.433
|
|
COVID-19 in the family
|
20 (3.6)
|
11 (5.2)
|
0.320
|
–
|
0.473
|
|
Geographic location
|
|
Central West
|
104 (18.8)
|
46 (21.8)
|
–
|
–
|
–
|
|
North
|
125 (22.6)
|
36 (17.1)
|
0.125
|
–
|
0.139
|
|
Northeast
|
86 (15.6)
|
20 (9.5)
|
0.048
|
–
|
0,064
|
|
South
|
123 (22.3)
|
58 (27.5)
|
0.881
|
–
|
0.910
|
|
Southeast
|
114 (20.7)
|
51 (24.2)
|
0.940
|
–
|
0.821
|
Abbreviations: aOR: adjusted odds ratio; AVR: average rank; CI: confidence interval.
Data are presented as median (average rank) or number (percentage); aChi-squared test; b Logistic regression to identify independent variables; cWhite versus nonwhite; d Black versus. nonblack.
The correlation analysis of the scores of questionnaire items on the knowledge and
concerns of the mother about COVID-19 with the BAI score are presented in [Table 4]. After adjustment by multiple regression, there was a positive and significant correlation
between the total BAI score and the items referring to: being informed about care
in the pandemic (rpartial 0.15; p < 0.001); concern about vertical transmission (rpartial 0.10; p = 0.01); be guided on breastfeeding (rpartial 0.08; p = 0.03); concern about difficulties in prenatal care during the pandemic (rpartial 0.10; p = 0.01), and concern about the baby contracting COVID-19 (rpartial 0.11; p = 0.004). The following variables were protective for maternal anxiety: self-confidence
in protecting from COVID-19 (rpartial - 0.08; p = 0.04), having learned (rpartial - 0.09; p = 0.01) and having self-confidence in breastfeeding (rpartial - 0.22; p < 0.001) in the context of the pandemic.
Table 4
Rank correlation analysis between maternal knowledge and concern items scores and
Beck Anxiety Inventory total score
|
Questionnaire items
|
Rho
|
p-value
[a]
|
Coefficient
|
Standard error
|
t
|
p-value
b
|
rpartial
|
|
Knowledge and preventive care
|
|
|
|
|
|
–
|
–
|
|
I am afraid about getting COVID-19.
|
−0.033
|
0.367
|
−0.409
|
0.323
|
−1.27
|
0.206
|
−0.046
|
|
I know the signs and symptoms of COVID-19.
|
−0.033
|
0.364
|
−0.410
|
0.307
|
−1.34
|
0.182
|
−0.049
|
|
I received information about care in the pandemic.
|
0.104
|
0.004
|
1.350
|
0.334
|
4.05
|
<0.001
|
0.147
|
|
I feel confident in protecting myself from COVID-19.
|
−0.073
|
0.043
|
−0.630
|
0.298
|
−2.11
|
0.035
|
−0.077
|
|
Prenatal concerns
|
|
I was worried about COVID-19 affecting my baby during pregnancy.
|
0.074
|
0.040
|
1.059
|
0.382
|
2.77
|
0.006
|
0.101
|
|
I was instructed on caring for the newborn.
|
0.025
|
0.495
|
−0.362
|
0.313
|
−1.16
|
0.247
|
−0.043
|
|
I was guided on breastfeeding during COVID-19.
|
0.093
|
0.010
|
0.630
|
0.288
|
2.18
|
0.029
|
0.080
|
|
I was worried about prenatal difficulties.
|
0.067
|
0.063
|
0.796
|
0.300
|
2.65
|
0.008
|
0.097
|
|
Cautions and fears during childbirth
|
|
I received guidance on childbirth care due to COVID-19.
|
0.031
|
0.395
|
0.134
|
0.237
|
0.56
|
0.573
|
0.021
|
|
My companion was afraid of COVID-19 at delivery.
|
0.076
|
0.036
|
0.171
|
0.253
|
0.68
|
0.499
|
0.025
|
|
I was worried about giving birth at the hospital.
|
−0.020
|
0.582
|
−0.107
|
0.283
|
−0.38
|
0.706
|
−0.014
|
|
I was afraid to be without a companion at childbirth.
|
0.030
|
0.412
|
0.181
|
0.319
|
0.57
|
0.572
|
0.021
|
|
I was worried that childbirth care might be compromised due to COVID-19.
|
−0.030
|
0.406
|
−0.113
|
0.272
|
−0.42
|
0.678
|
−0.015
|
|
Care and concerns about the newborn
|
|
I learned how to breastfeed due to COVID-19.
|
−0.050
|
0.164
|
−0.614
|
0.245
|
−2.51
|
0.012
|
−0.092
|
|
I feel confident to breastfeed despite COVID-19.
|
−0.161
|
<0.001
|
−2.369
|
0.382
|
−6.20
|
<0.001
|
−0.222
|
|
I am worried about having COVID-19.
|
0.009
|
0.798
|
−0.637
|
0.360
|
−1.77
|
0.077
|
−0.065
|
|
I am worried that my baby has COVID-19.
|
0.011
|
0.757
|
−0.321
|
0.301
|
−1.07
|
0.287
|
−0.039
|
|
I am worried about my baby having COVID-19 after birth.
|
0.093
|
0.010
|
1.208
|
0.413
|
2.92
|
0.004
|
0.107
|
|
(Constant)
|
–
|
–
|
13.166
|
–
|
–
|
–
|
–
|
a Spearman correlation; b Multiple regression with enter procedure to identify independent variables.
Discussion
This is the first multicenter study in Brazil to investigate anxiety of pregnant women
without medical or obstetrical comorbidities during the COVID-19 outbreak by face-to-face
interviews. Our study found moderate or severe anxiety in 27.6% of the healthy women
at the end of pregnancy. Moderate or severe maternal anxiety was associated with high
school educational level and not living with a partner. Women who were better informed
during the pandemic and who demonstrated concerns about prenatal care, vertical transmission,
or about the baby contracting COVID-19 presented increased maternal anxiety evaluated
by the BAI total score. Self-confidence in protecting against COVID-19 and knowledge
about breastfeeding care during the pandemic reduced maternal anxiety.
The COVID-19 pandemic has led to adverse mental health consequences in the general
population.[12] Multiple COVID-19-related factors should be considered, such as perceived risk and
concerns about infection, full and partial lockdowns, and social restriction measures.[13] Studies have examined general anxiety related to worries about the self and the
baby during COVID-19 pandemic.[9]
[14]
[15] Matvienko-Sikar et al.[16] found significant decreases in the perceived social support from all sources by
pregnant women during the COVID-19 pandemic, and a nonsignificant increase in stress.
Our study found that anxiety was decreased in those living with a partner, which is
an important factor of social support in our culture.
Several patient groups were found to be more vulnerable to COVID-19 during the pandemic,
and pregnant women are at a higher risk of death in Brazil.[17] Maternal and fetal effects, as well as the best management of COVID-19 in pregnancy,
have not been completely elucidated.[18] These uncertainties and changes may be the main aspects related to maternal anxiety
during the pandemic.
Women are less concerned about their own health; nevertheless, many of them were significantly
anxious. In Wuhan, China, the COVID-19 outbreak increased the anxiety of pregnant
women and affected their decision-making regarding prenatal care schedules or timing
of childbirth, mode of delivery, and infant feeding.[19] Wu et al.[20] reported depressive symptoms in 29.6% of pregnant women after the declaration of
an epidemic. In Belgium, an online survey during the lockdown period revealed that
14% of pregnant and breastfeeding women met the criteria for high anxiety.[21] Interventions targeting maternal stress and isolation, such as effective communication
and psychological support, should be offered to decrease these mental health effects.
In the present study, data were collected from all geographic regions in Brazil during
the same period. Maternal anxiety was more prevalent and more severe in the Central
West and in the South regions during the studied period. At that time, COVID-19 was
receding in the North and in the Northeast and increasing in the South and in the
Central West. This may have influenced the prevalence of maternal anxiety. The notifications
of increased numbers of deaths could potentially impact maternal mental health, and
the risk of anxiety disorders may have increased as a result. Liu et al.[19] found that more women felt anxious in Wuhan than in Chongqing, because the first
city was more affected by COVID-19. Brazil has great disparities among regions, not
only in COVID-19 mortality cases, but in other health indicators and in social, cultural,
and economic characteristics.
Another source of concern is not being able to reach the prenatal care appointments.
Even though uninterrupted prenatal care was provided during the pandemic, the frequency
of appointments diminished, and the same occurred with exams and ultrasounds. The
uncertainty about the best treatment and clinical management of patients with COVID-19
may also affect the mind of pregnant women.[22] Uncertain prognosis, social restrictions, economic financial losses, decline in
quality of life, and conflicting messages from government authorities are additional
stressors and, possibly, trigger mental health crises.
An online survey in Belgium revealed higher levels of overall anxiety among pregnant
women, 8.4% of whom had moderate and 5.2% had severe anxiety.[21] We found 16.1% cases of moderate anxiety and 11.5% cases of severe anxiety. These
differences may be related to the fact that we conducted face-to-face, not online,
interviews,. We also found that high school educational level and not living with
a partner were associated with higher scores on the total BAI, indicating that social
support should be improved during antenatal care. It is important for women to have
adequate support, which includes health care workers and companions during labor and
childbirth, to improve their mental well-being. Specific interventions that aim to
reduce COVID-19 stress may help to reduce overall stress levels in pregnant women
during the pandemic.[23]
The strength of the present study lies in the inclusion of 10 cities in all geographic
regions in Brazil, most of which are state capitals. Additionally, the women were
interviewed face-to-face, not through online forms or phone calls. All the interviews
were performed by trained doctors who were available to answer questions and minimize
concerns. Our study has the limitation of including only women from receiving care
from the public sector in university hospitals. Another limitation is that the emergence
of COVID-19 was different in each geographic region, which present organizational
differences in health systems in cities, and this may have influenced the quality
of health care.
Conclusion
Anxiety of pregnant women without medical or obstetrical comorbidities was related
to high school educational level and not living with a partner during the COVID-19
pandemic. Women who were better informed during the pandemic and who demonstrated
concerns about prenatal care, vertical transmission, or about the baby contracting
COVID-19 presented increased maternal anxiety. Self-confidence in protecting against
COVID-19 and knowledge about breastfeeding care during the pandemic reduced maternal
anxiety.
