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Journal Information

Online ISSN (English)
1305-3124

Print ISSN (Turkish)
1300-5251

Online ISSN (Turkish)
1305-3132

Established
1993

Editor-in-Chief
Cihat Şen

Editors
Murat Yayla, Oluş Api

Comparison of the levels of antenatal anxiety in pregnant women admitted for delivery before and after COVID-19 outbreak in Turkey

Oğuz Güler, Şafak Hatırnaz

Article info

Comparison of the levels of antenatal anxiety in pregnant women admitted for delivery before and after COVID-19 outbreak in Turkey. Perinatal Journal 2020;28(2):- DOI: 10.2399/prn.20.0282014

Author(s) Information

Oğuz Güler1,
Şafak Hatırnaz2

  1. Bilge Hospital İstanbul TR
  2. Medicana Samsun International Hospital, IVF center Samsun TR
Correspondence

Oğuz Güler, Bilge Hospital İstanbul TR, oguz_gulers@yahoo.com

Publication History

Manuscript Received: June 01, 2020

Manuscript Accepted: June 17, 2020

Earlyview Date: June 17, 2020

Conflicts of Interest

No conflicts declared.

Objective
This study aimed to compare the level of anxiety in pregnant women who were admitted to our institute before and after confirmation of COVID-19 outbreak have reached Turkey.
Methods
One-hundred and fifty consecutive pregnant women admitted to our institute following the emergence of the global COVID-19 outbreak (Group 1) and 150 age-matched pregnant women who were admitted to our institute for delivery following the confirmation of COVID-19 outbreak have reached Turkey (Group 2) were enrolled in this study. All patients were asked to fill out the State and Trait Anxiety Inventory (STAI).
Results
STAI-Trait scores, which reflect long term anxiety levels were similar in subjects admitted to our institute for delivery before the COVID-19 outbreak in Turkey compared to those admitted after COVID-19 outbreak (42.5 ± 5.8 vs. 42.2 ± 3.2, respectively, p=0.487). However, there was a significant difference in STAI-State scores, indicating state anxiety, between subjects admitted to our institute for delivery before and after confirmation of COVID-19 outbreak in Turkey (44.6 ± 5.3 vs. 42.9 ± 5.1, respectively, p=0.05).
Conclusion
Pregnant women admitted to our institute for delivery subsequent to the announcement of first COVID-19 case and declaration of the state of alarm have higher level of state anxiety compared to those admitted before the establishment of first COVID-19 cases and containment measures.
Keywords

COVID-19, antenatal anxiety, pregnant

Introduction
Several cases of pneumonia with unknown etiology have emerged in Wuhan, Hubei Province, China towards the end of the 2019 [1]. Fewer and cough, which were prior to an acute respiratory distress syndrome were the most prominent initial symptoms [2]. Following the identification of a novel coronavirus in the throat swab sample of one patient by the Chinese Center for Disease Control and Prevention (CDC), World Health Organization (WHO) named the novel coronavirus as 2019nCoV [3]. The rapid spread of the pneumonia to other regions of China and overseas led World Health Organization (WHO) declare this outbreak as the public health emergency of international concern (PHEIC). In February 2020, the virus was renamed as severe acute respiratory syndrome coronaviruse-2(SARS-CoV-2) by the International Committee on Taxonomy of Viruses [4]. Epidemic disease caused by SARS-CoV-2 was further announced by the WHO as coronavirus disease 2019 (COVID-19).

Coronavirus disease 2019 was the third coronavirus disease within the last two decades following severe acute respiratory syndrome coronavirus (SARS-CoV) which resulted in more than 8000 infections and 774 deaths in 37 countries, and Middle East respiratory syndrome coronavirus (MERS-CoV) which resulted in 2494 infections 858 deaths [5, 6]. As of May 25, 2020, COVID-19 has been reported to affect about 5.5 million individuals and caused over 340.000 fatalities globally [5]. The high virulence, rapid spread and related mortality alerted healthcare authorities and many of the countries announced containment measures to slow-down the spread of the COVID-19. Accumulating data indicate that declaration of the state of alarm by many countries and related containment measures along with the public-health messages not only raised public’s knowledge concerning the COVID-19 but also led to global anxiety resulting from the fear of being infected by the SARS-CoV-2 [7-10].  A number of studies have shown that antenatal anxiety could result in adverse perinatal outcomes [11]. Given that, COVID-19 may trigger excessive anxiety, we hypothesized that the announcement of containment measures as a consequence of the arrival of COVID-19 in our country would trigger anxiety in pregnant women.
This study aimed to compare the level of anxiety in pregnant women who were admitted to our institute before and after confirmation of COVID-19 outbreak have reached Turkey.
Methods
One-hundred and fifty consecutive pregnant women aged between 18 and 35 years who were admitted to the our hospital following the emergence of the global COVID-19 outbreak (Group 1) and 150 age-matched pregnant women who were admitted to our institute for delivery following the confirmation of COVID-19 outbreak have reached Turkey (Group 2, before March 11, 2020) were enrolled in this study. Women with previous anxiety disorders or mental syndromes, high blood pressure, lung, kidney, or heart problems, diabetes, autoimmune disease, sexually transmitted diseases, preeclampsia, multiple pregnancies, placenta previa were excluded. Written informed consent was obtained from all subjects included in the study. The study was approved by the Institutional Ethical Committee and was performed in accordance with the recent version of the Helsinki Declaration. The power calculation was based on our pilot study with the first 15 patients. We used “priori t-tests; the difference between two independent means” for post-information STAI state (STAI-S) measurements in the two groups (Group 2 patients: 45.3 ± 4.6, STAI-S score of Group 1 patients: 42.4 ± 4.2, alpha error: 0.05, power: 0.95, effects size: 0.65) [12]. Results showed that at least 102 patients were required for an adequate sample size.

All patients were asked to fill out the State and Trait Anxiety Inventory (STAI), which is a validated and widely used self-report questionnaire assessing both state and trait anxiety [13, 14]. STAI includes two questionnaires with 20 questions in each; STAI-State, which intends to evaluate the current state of anxiety, and trait anxiety (STAI-Trait) that measures long term anxiety levels.  Responses for the STAI-State scale evaluate the intensity of current feelings “right now”: 1) not at all, 2) somewhat, 3) moderately so, and 4) very much so. Responses for the STAI-Trait scale evaluate the frequency of feelings “in general”: 1) almost never, 2) sometimes, 3) often, and 4) almost always. Item scores are added to obtain subtest total scores. Each answer was scored on a scale of 1-4 and was added to reach a final score.  The overall score ranges between 20 and 80, the higher score indicating greater anxiety.

The difference between the anxiety levels of subjects in Group1 and Group 2 was the primary outcome measure of this study. Statistical analyses were carried out using SPSS for Windows, version 17 (SPSS, Chicago, IL, USA). Continuous variables were presented as mean ± standard deviation (mean ± SD) and categorical variables as frequency (n) and percentage (%). Kolmogorov-Smirnov test was used to determine the normal distribution of the data. The comparison of the two groups was performed with Student’s t-test, Mann–Whitney U-test, χ2 -test or Fisher’s exact test, where appropriate. Two-sided p-value ≤ 0.05 was interpreted as statistically significant.
Results
The mean age and the mean gestational week of the study subjects were 28.6 ± 4.7 years and 35.5 ± 2.1 weeks, respectively. The two groups were similar with respect to age, gestational week, body mass index, gravidity, and parity. STAI-Trait scores, which reflect long term anxiety levels were similar in subjects admitted to our institute for delivery before the confirmation of COVID-19 outbreak have reached our country compared to those admitted after COVID-19 outbreak have reached our country (42.5 ± 5.8 vs. 42.2 ± 3.2, respectively, p=0.487). However, there was a significant difference in STAI-State scores, indicating state anxiety, between the subjects admitted to our institute for delivery before and after confirmation of COVID-19 outbreak have reached our country (44.6 ± 5.3 vs. 42.9 ± 5.1, respectively, p=0.05).
Discussion
Despite similar long-term anxiety scores between the two groups,our findings show that subjects admitted to our institute for delivery following the confirmation of COVID-19 outbreak have reached our country had higher level of state anxiety compared to subjects admitted before the confirmation of COVID-19 outbreak have reached our country.
Antenatal anxiety, which is shown to affect about 20% of pregnant women, has been reported to be associated with adverse outcomes for both mother and baby following delivery [15]. While postpartum hemorrhage, and postpartum depression are more frequent in pregnant with antenatal anxiety, preterm birth, low mean birth weight, and small head circumference might be observed in infant born to mothers with antenatal anxiety [16-20]. Moreover, measures aiming to relieve anxiety have been shown to improve pregnancy outcomes in women with antenatal anxiety [21, 22].

Turkish ministry of Health announced the first COVID-19 case in Turkey in March 11, 2020. A state of alarm, including several containment measures such as school closures, transport bans and workplace shutdowns has been established following this first case. Individuals <20 years and > 65 years were obliged to stay at home since this population may either be vulnerable to complications of COVID-19 or may facilitate the spreading of the COVID-19. Elective interventional and surgical procedures were also postponed due to the heavy burden on the healthcare systems loaded by COVID-19 cases. Television programs started to broadcast certain public messages regarding the virulence and rapid spread of SARS-CoV-2 and global mortality from COVID-19. Following the establishment of containment measures by governments, many of the individuals are observed to hesitate seeking medical help even for emergency situations [23]. There are several recent reports demonstrating a dramatic decline in hospital admissions even from life-threatening conditions such as acute myocardial infarction or acute heart failure after containment measures [24-26].  It simply appears that declaration of the state of alarm by many countries and related containment measures along with the public-health messages have created a global anxiety among individuals requiring healthcare for causes other than COVID-19 and led to a self-censorship resulting from the possible contamination in hospitals. A recent study from China has shown that initial phase of the COVID-19 outbreak triggered extensive anxiety among general population [7].  Another study among active Weibo users has reported short-term individual changes in psychological conditions after the outbreak [27].

Currently, there are only a few studies investigated the role of COVID-19 outbreak on antenatal anxiety. The study of Durankus et al., which included an online questionnaire consisting of depression and anxiety inventories, has shown that COVID-19 pandemic had critical impact on the depression and anxiety levels of pregnant women [28]. A multi-center cross-sectional study from China, which compared the mental status of pregnant women before and after the announcement of the COVID-19 epidemic has reported that pregnant women assessed after the declaration of COVID-19 epidemic had significantly higher level of anxiety and higher rates of depressive symptoms compared to women assessed prior to announcement of the COVID-19 epidemic [29]. However, there is still gap in data regarding the role of COVID-19 outbreak on antenatal anxiety.

This study shows that pregnant women admitted after announcement of the first COVID-19 case and containment measures in Turkey had higher level of anxiety compared to women admitted before containment measures. Our findings confirm the results of the previous two studies indicating higher level of anxiety in pregnant women following the COVID-19 outbreak. The lack of a significant difference in STAI-trait scores between subjects admitted before and after COVID-19 outbreak indicates that psychological impact of the outbreak is short-term and is associated with either the COVID-19 outbreak itself or with the containment measures established to prevent the spread of the disease. Strategies targeting to relieve maternal stress should be provided by all decision-makers, health authorities, and health care professionals to prevent potential adverse pregnancy outcomes which are closely linked with antenatal anxiety.
Conclusion
Results of this study clearly shows that pregnant women admitted to our institute for delivery subsequent to the announcement of first COVID-19 case and declaration of the state of alarm have higher level of state anxiety compared to those admitted before the establishment of first COVID-19 cases and containment measures. Given the negative impact of antenatal anxiety on pregnancy outcomes, we consider that heath authorities should provide strategies targeting to relieve maternal stress on pregnant women.
 
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Table 1.
Comparison of demographic features and anxiety scores between the study groups
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