key: cord-0706093-vlra98ri authors: Brik, Maia; Sandonis, Miguel Angel; Fernández, Sara; Suy, Anna; Parramon‐Puig, Gemma; Maiz, Nerea; Dip, Maria Emilia; Ramos‐Quiroga, Josep Antoni; Carreras, Elena title: Psychological impact and social support in pregnant women during lockdown due to SARS‐CoV2 pandemic: A cohort study date: 2021-02-02 journal: Acta Obstet Gynecol Scand DOI: 10.1111/aogs.14073 sha: aac1104934153c8ee875a80a68e8777b61ef1377 doc_id: 706093 cord_uid: vlra98ri INTRODUCTION: Anxiety and depression during pregnancy can lead to adverse maternal and neonatal outcomes. The SARS CoV‐2 pandemic, and the complete lockdown required during the first wave in most countries are stressors for pregnant women and can lead to anxiety and depression during pregnancy. The aim of this study was to explore depression and anxiety symptoms, and social support in pregnant women during the SARS CoV‐2 lockdown, as well as to explore demographic risk factors. MATERIAL AND METHODS: A prospective cohort study was performed at Hospital Universitari Vall d’Hebron, Barcelona, including pregnant women attending the antenatal clinic during the SARS‐CoV2 lockdown period. Three questionnaires were administered to study depression (EPDS), anxiety (STAI) and Social Support (MOS‐SSS). STAI state (STAIs) described the actual state of anxiety and the STAI trait (STAIt) described the trait of anxiety. A cut‐off of 10 for EPDS and 40 for STAI was considered to be clinically relevant. The main outcome measures were depression and anxiety symptoms. RESULTS: A total of 217 women were invited to participate, and 204 accepted (94%). From these, 164 filled in the EPDS, 109 STAI and 159 MOS‐SSS questionnaires: 37.8% (95% confidence interval [CI] 30.5%‐45.7%) (62/164) of women showed an EPDS result ≥10, 59.6% (95% CI 49.8%‐68.8%) (65/109) a STAI state (STAIs) ≥40, and 58.7% (95% CI 48.9%‐67.9%) (64/109) a STAI trait (STAIt) ≥40. Regression analysis showed that mental health disorder, Latin American origin and lack of social support were independent risk factors for anxiety symptoms in the STAIs (P = .032, P = .040 and P = .029, respectively). Regarding depressive symptoms, maternal body mass index, mental health disorders and social support were independent factors (P = .013, P = .015 and P = .000, respectively). CONCLUSIONS: A lockdown scenario during the first wave of the SARS‐CoV 2 pandemic increased the symptoms of anxiety and depression among pregnant women, particularly affecting those with less social support. The novel coronavirus SARS-CoV-2 was first detected in Wuhan (Hubei Province, China) in December 2019. From that moment, it began to spread first in China, and all over the world. Direct personto person transmission is the primary means of transmission of SARS CoV-2. It is thought to occur through close-range contact, mainly via respiratory droplets, when an infected person coughs, sneezes or talks. On 11 March 2020, the World Health Organization declared COVID-19 a global pandemic. Confirmed cases and deaths grew rapidly, with more than 73 000 000 confirmed cases worldwide by 16 December 2020, and more than 1 600 000 deaths from it (Johns Hopkins University & Medicine, 2020). Spain has been one of the worst hit countries, with more than 48 000 deaths by 16 December On 14 March 2020, the Spanish government declared a national state of alert and population lockdown was imposed as of 16 March, where all the population was confined at home for 98 days, excepting essential activities. This is the first experience of a global emergency due to a virus pandemic in our century, leading to great uncertainty and significant adverse consequences for mental health. 1,2 Quarantine is associated with psychological consequences such as symptoms of posttraumatic stress disorder and depression, 1 but there is no comparable situation to a national lockdown. Pregnant women are a particularly vulnerable group during the pandemic. In this population, the initial lack of evidence about the possible effects of the virus on pregnancy, the fetus or potential teratogenic effects of antivirals were additional factors increasing the risk for mental health disorders beyond the lockdown itself. The prevalence of anxiety disorder in the general population is 13.6%, 3 and increases to 15.2% during pregnancy. 4 Regarding major depression, the prevalence rate in the general population is 2.8% and 7.4%-12.8% during pregnancy. 5 In previous epidemics such as severe acute respiratory syndrome (SARS) in 2003, pregnancy worsened the clinical course and the prognosis of the disease itself. 6 In the Zika outbreak in 2016, central nervous system malformations occurred as a result of vertical infection. 7 Stressors during pregnancy, such as traumatic psychological events and low socioeconomic status, as well as the presence of depression and anxiety, are associated with poorer obstetric and infant outcomes, including increased risk of preterm birth, 8 delayed early cognitive development, 9 changes in brain structure and connectivity, 10 behavioral and motor differences during early childhood and psychological disorders into adulthood. 11 Little research has focused on the psychological impact of pandemic during the lockdown suffered by pregnant women. The aim of the present study is to explore depression and anxiety symptoms of pregnant women during lockdown due to SARS CoV-2 pandemic, as well as to detect risk factors for the development of these symptoms that could lead to early healthcare interventions in the future. Secondary objectives were to compare depression and anxiety symptoms according to the lockdown period and the trimester of pregnancy. A prospective cohort study was performed in Hospital Universitari Vall d'Hebron, Barcelona, Spain with a recruitment period from 27 March to 4 May 2020. As the cases of COVID-19 increased, strict measures for lockdown were imposed by the authorities from 15 March to 4 May 2020, with all non-essential workers being ordered to remain at home and outdoor activities banned. From 4 May to 21 June 2020 workers were allowed to go to work (where essential) and minimal outdoor activities were allowed, restricted to a few hours per day. In all, 217 pregnant women attending at the Vall d´Hebron University Hospital for their antenatal visits were offered participation in the study. This hospital services a population of 1 200 000 inhabitants and is the reference for tertiary services. It delivers 2900 births per year with a medium to low socioeconomic background population compared with the province of Barcelona. Not being able to understand Spanish was an exclusion criterion. The Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI) and the Medical Outcomes Study Social Support Survey (MOS-SSS) questionnaires were administered on paper, by email or by telephone. For paper questionnaires, our hospital's procedures and policies to prevent SARS-CoV2 infection spread were followed, including the use of hand sanitizer. These three rating scales measure the levels of depression, anxiety and social support, respectively. The EPDS is a 10-item self-report scale designed as a specific instrument to detect postnatal depression. Each item is rated on anxiety, COVID-19, depression, pandemic, pregnancy, SARS-CoV-2, social support The SARS-CoV-2 lockdown in Spain was associated with increased symptoms of depression and anxiety among pregnant women. Women with increased body mass index and lower social support showed a higher risk for depression and anxiety. a 4-point scale ranging from 0 to 3, with higher scores indicating greater severity. 12 The best cut-off of the Spanish validation of the EPDS was 10/11 for combined major and minor depression, with a sensitivity of 79% and specificity of 95.5%, with a positive predictive value of 63.2% and a negative predictive value of 97.7%. 13, 14 The STAI is a 40-item self-report scale for state (STAIs) and trait (STAIt) anxiety. It is the most commonly used rating scale for anxiety and has been widely validated. 15 Each item is rated on a 4-point scale ranging from 0 to 3, with higher scores indicating greater severity. For the comparison with international studies, the 4-point scale ranging from 0 to 3 was transformed to 1-4. It has also been validated for use in pregnant women. 16 Continuous variables were expressed as median and interquartile range (IQR) or mean and standard deviation. Categorical variables were expressed as frequency and percentage. Mann-Whitney test was used to compare the levels of anxiety and depression between the two lockdown periods, and Kruskal-Wallis test to compare the anxiety and depression levels among the three trimesters of pregnancy. A univariate linear regression analysis was used to identify risk factors for depression and anxiety symptoms. SPSS software, IBM SPSS Statistics for Windows, version 23 (IBM Corp.), and R were used for statistical purposes. All reported probability values were two-tailored, and the criterion for significance was set as P = .05. Informed consent was obtained from all participants. A total of 217 pregnant women attending our hospital during the lockdown period were offered participation in the study; 204 of them accepted (94%) and were included in the study. The sociodemographic and clinical characteristics are summarized in Table 1 When analyzing the impact on EPDS results depending on the trimester of inclusion in the study, with higher results were found in patients enrolled in the first and second trimester than in the third trimester. The median and interquartile range for the EPDS result (Figures 2 and 3 ). and P = .000, respectively) were identified as independent predictive risk factors (Table 3 ). There was a positive correlation between maternal BMI and EPDS result (R 2 = .038). (Table 4 ). The present study suggests that a stressful situation such as an infectious pandemic, can lead to an increase in anxiety and depression symptoms among pregnant women. 3, 5 The presence of mental health disorders was also predictive for both anxiety and depression symptoms, with maternal BMI being a risk factor for depression symptoms. In addition, a low level of social support had a clear impact on increased levels of anxiety and depression. This research is a unique opportunity to explore the emotional impact of lockdown during pregnancy, and the influence of social support. The main goal of our study was to identify how anxiety and depression can be affected by the lockdown in this particular population. Social support was included as a potential risk factor for depression and anxiety in this scenario, and was shown to be a determinant factor. An important limitation of the study was challenges as to partic- is not yet been established for the current SARS CoV2 pandemic, and warrants further research. The prevalence of anxiety in the general population is about 13.6%. 3 The prevalence of clinical anxiety during pregnancy in non-pandemic conditions is about 15.2%. 4, 17, 24 In contrast, our study showed that the prevalence of pregnant women with anxiety symptoms was 59% during COVID19 pandemic lockdown. Table 5 shows the prevalence rates of depression and anxiety in general and pregnant population in non-pandemic and during SARS CoV2 pandemic, in comparison with our study results. Situations that increase stress, such as a global pandemic situation, are additional factors that may predispose to anxiety, and this explains the higher results in the STAI questionnaire results in our study population. 21 Regarding the influence of the lockdown occurring early or late during pregnancy, a prevalence of clinical anxiety of 18%, 15.2% and 15.4% during the first, second and third trimesters, respectively, has been reported during non-complicated pregnancies. 24 In our study, no differences were found according to the trimester of pregnancy in the STAIs or STAIt results. However, differences were found in the EPDS results during the lockdown. The prevalence of depression during pregnancy has been reported to be 7.4%, 12.8% and 12.0% for the first, second and third trimesters, respectively. 5 Our study also found that the prevalence of symptoms of depression was higher for women during the first and second trimesters than during the third trimester, probably related to higher risks of fetal loss during the beginning of the pregnancy. The period of lockdown appeared to have no impact based on the EPDS and STAI questionnaires. During the lockdown, the first period was associated with greater uncertainty about the pandemic and less available data; accordingly, anxiety in the general population during this period was higher. However, our study could not identify such an effect on anxiety or depression symptoms in pregnant women, which could be related to the reduced sample size in our study. Moreover, our study found that women with previous mental health disorders showed better scores in both depression and anxiety symptoms. The explanation for these results could be that those patients who had a previous history mental health disorders could develop increased resilience and thus, its presence may act as a protective factor. 25 In addition, the fact that one-third of women with mental health disorders were receiving pharmacological treatment could also explain this result. High BMI has been identified as an independent factor for depression. Women with obesity are especially vulnerable to antenatal depression. 26 This is in line with findings in the general population that show a positive association between obesity and depression, particularly among women. 27 However, in a recent SARS-CoV2 pandemic research on pregnancy, women underweight before pregnancy were at increased risk for developing depressive and anxiety symptoms during the pandemic, 28 but not those with overweight. Finally, our study demonstrated the impact of the lack of social support on the development of anxiety and depression symptoms during pregnancy. We therefore hypothesize that the implementation of programs that offer additional social support during pregnancy, may be helpful in reducing anxiety and depression symptoms, as well as the likelihood of cesarean birth and antenatal hospital admission. 29 Also, social support during pregnancy may itself provide a buffering mechanism between stress and preterm birth. 30 study, lower social support was a risk factor for both anxiety and depression symptoms and this is precisely the population that should be the target of new interventional strategies to prevent the emotional impact in a new possible viral pandemic. A lockdown scenario during a pandemic situation increases symptoms of anxiety and depression among pregnant women. Also, pregnant women with low social support are at increased of developing anxiety and depression symptoms. These results highlight the need to improve mental healthcare during pregnancy, especially in exceptional circumstances such as the global pandemic situation or lockdown, as these can cause added stress and increased anxiety and depression symptoms, resulting in undesirable consequences for pregnancy and the future newborn. 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