Background: Pregnancy is a fragile state, and it is prone to anxiety and depression which may affect the outcome of pregnancy. Due to the unprecedented COVID pandemic, health-care services were limited to emergency care which hampered mental well-being of pregnant women.
Objective: The present study was aimed to assess the stress related to COVID-19 in pregnant and nonpregnant women.
Subjects and Methods: It was a field-based comparative cross-sectional study, conducted in the urban field practicing area of Osmania Medical College, Hyderabad, Telangana, for a period of 3 months during the second wave of the COVID pandemic, among 120 pregnant and 120 nonpregnant women. The questionnaire consisted of sociodemographic details, experiences with COVID-19 and lockdown, KAP on COVID-19, impact on health-care services, and various stress scales (Perceived Stress Scale [PSS], Generalized Anxiety Disorder (GAD), and World Health Organization Disability Assessment Schedule [DAS] 2.0).
Results: Majority of the study population were in the 18–35 years of age group; there were higher PSS mean score, GAD-7 mean Score, and DAS 2.0 mean score, among pregnant women compared nonpregnant women. PSS mean score for pregnant women was 18.80 ± 3.779 and for nonpregnant women was 12.50 ± 3.098 (P < 0.00001). GAD-7 mean score for pregnant women was 5.50 ± 3.087 and for nonpregnant women was 2.20 ± 1.804 (P < 0.00001). DAS 2.0 mean score for pregnant women was 22.87 ± 7.033 and for nonpregnant women was 16.10 ± 6.432 (P < 0.00001). Practices of preventive measures of COVID-19 were appropriate among both the groups.
Conclusion: Although both the groups were affected mentally by the pandemic, stress, anxiety, and disability were common among the pregnant women.
Keywords: COVID-19, stress, pregnant
|How to cite this URL:|
Anjum S, Mohiuddin SA, Kenche B. A comparative cross-sectional study among pregnant and nonpregnant women on stress related to COVID-19 in Hyderabad, Telangana. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=362526
| Introduction|| |
Pregnancy is a state of physiological, emotional, and mental stress, which can manifest in various forms such as anxiety, mood swings, and depression with a prevalence ranging from 5% to 16%. The action of many maternal hormones causes a woman's body to change in a variety of ways throughout pregnancy. These changes might be uncomfortable at times and may cause stress during pregnancy. It is typical for a pregnant woman to be psychologically unsettled and worried about her health, her baby's well-being, and the changes that will occur in her life after the child is born. However, pregnancy is a period of delight for most women, laced with the pleasure and anticipation of a new family member. On January 30, 2020, the World Health Organization (WHO) labeled the COVID-19 (the disease caused by severe acute respiratory syndrome coronavirus 2) outbreak a global emergency, which showed a ripple effect on every stage of human life. Pregnant women were recognized as a susceptible category and were recommended to take extra measures, while the COVID-19 pandemic emerged because they are at a higher risk of complications and severe disease., Many nations, including India, reacted by limiting freedom of travel and limiting nonemergency health care to focus resources on COVID-19 care provision, which had a significant influence on antenatal, intranatal, and postnatal services. As a result of that, fear seized pregnant women all throughout the world and left them prone to stress. There is mounting evidence that even milder kinds of stress or anxiety during pregnancy harm the baby and potentially having long-term effects on newborn and child development.
The present study was aimed at assessing the level of mental health in terms of perceived stress, anxiety, and disability present among the pregnant women when compared to nonpregnant women during the COVID-19 pandemic by various scales (Perceived Stress Scale [PSS], Generalized Anxiety Disorder [GAD], and WHO Disability Assessment Schedule [DAS] 2.0 scores). This study also assessed sociodemographic factors and the practices of prevention measures (COVID-19) among both pregnant and nonpregnant women.
| Subjects and Methods|| |
Material and Methods
The present study was a field-based comparative cross-sectional study conducted in the urban field practicing area of Osmania Medical College, Hyderabad, Telangana, for a period of 3 months (January–March 2021). Sample size was calculated based on the pilot study prevalence p1 = 55% (proportion of pregnant women with stress), p2 = 36% (proportion of nonpregnant women with stress) with 95% significance level and 80% of power using the formula N = ([Z1 − a/2 + Z1−β]2 [P1Q1 + P2Q2]) (P1 − P2)2 which gave 107 as the minimum sample size for each group. Taking 10% as nonrespondents, we got 118 (117.7); we rounded the value to 120. Hence, we recruited 120 pregnant women as the study group and 120 nonpregnant women as the comparative group which is above the minimum sample size. The ANC register of the Urban Health Centre had 238 registered pregnancies. Using simple random sampling, using lottery method, we picked up 120 pregnant women. Every consecutive woman of the reproductive age group who were nonpregnant, women visiting the OPD of the Urban Health Centre for some other medical causes, and those who gave consent were included in the comparative group.
The women who were between the age group of 15 and 49 years with confirmed pregnancy, those who understood Hindi/Urdu and English language, and those who gave consent for interviewing were included in the study. Those women who were unmarried and were very ill to answer the questions were excluded from the study.
PSS was used as a psychological instrument for measuring the perception of stress., This scale was used in English and Hindi/Urdu language. Cronbach's alpha for PSS-10 in English version was >0.70 and Hindi version was 0.731. GAD 7-item (GAD-7) was performed as an initial screening tool for GAD. Cronbach's alpha for GAD-7 English version was 0.83 and Urdu version was 0.92. A generic assessment instrument for health and disability was done by the WHO DAS 2.0 scoring. Cronbach's alpha for DAS 2.0 was 0.98. Multilevel study done by the WHO proved that DAS 2.0 was unaffected by cultural or any sociodemographic factors. A questionnaire was prepared consisting of demographic details, experiences with COVID-19 and lockdown, KAP on COVID-19, and impact on health-care services.
Ethical clearance was taken from the Ethical Committee of Osmania Medical College, and informed consent was taken from the study subjects before doing this study.
Data were entered into MS-Excel 2007 and were analyzed using SPSS software trial version 22, IBM, United States. Relevant statistical tests (Chi-square test, t-test) were applied and P < 0.05 was considered statistical significance.
| Results|| |
[Table 1] shows that majority of the study population were in the 18–35 years of age group and educated up to primary/middle school. Majority of the study population were belonging to Hindu community and were homemakers. The difference between both the groups was not significant; therefore, they were comparable (P > 0.05).
[Table 2] shows that the low level of PSS score was more prevalent in nonpregnant women (63.3%) and the moderate level of PSS score more prevalent in pregnant women group (86.7%). The difference between the groups was significant (P < 0.00001).
|Table 2: Perceived Stress Scale, Generalized Anxiety Disorder 7-item, and Disability Assessment Schedule 2.0 score distribution|
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Moderate level of anxiety was only seen among pregnant women (23.3%), and majority of nonpregnant women had minimal anxiety (80%) according to GAD-7 score. Minimal anxiety group was compared with a combination of mild and moderate anxiety; this difference between the groups was significant (P < 0.00001).
Majority of pregnant women had mild disability and nonpregnant women had no disability according to DAS 2.0 score. This difference between the groups was significant (P < 0.0001).
[Table 3] shows that there was higher PSS mean score (mean difference 6.3), GAD-7 mean score (mean difference 3.3), and DAS 2.0 mean score (mean difference 6.7), among pregnant women compared nonpregnant women. This difference between the means among the groups was significant (P < 0.00001).
[Table 4] shows the practice of COVID preventive measures among both the groups. Pregnant women had more history of going into crowds during the pandemic, although majority were wearing a mask and followed social distancing when going outside. Knowledge about hand sanitization; avoiding touching eyes, nose, and mouth with unwashed hands; and using disinfectants to clean (when soap and water not available) was high in both the groups with no significant statistical difference (P > 0.05).
[Table 5] shows a mild-to-moderate positive correlation between PSS score with GAD-7 score (r = 0.36) and DAS 2.0 score (r = 0.36) [Figure 1] and [Figure 2].
|Figure 1: Correlation between gad and PSS scores. PSS: Perceived Stress Scale|
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|Figure 2: Correlation between DAS 2.0 and PSS scores. DAS: Disability Assessment Schedule, PSS: Perceived Stress Scale|
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| Discussion|| |
Depression is a typical concern for pregnant women even in normal times. The current comparative study sought to investigates nonpregnant and pregnant women's risk of depression during the unusual times of the COVID-19 era.
According to studies on stress in pregnant women, one out of every ten pregnant women reports high levels of stress, while around 40% perceive their lives as moderately stressful.
Majority of the present pregnant study population were in the 26–35 years of age group. In 2020, age of childbearing for India was 27.4 years. Age of childbearing of India fell gradually from 28.75 years in 1975 to 27.4 years in 2020, which supports the present study finding.
PSS was used as a psychological instrument for measuring the perception of stress in the present study, which showed higher PSS score more prevalent in pregnant women group when compared to nonpregnant. The mean pregnant women PSS score during the pandemic was 18.8, which is higher than the prepandemic level of PSS mean score (13.5) in an Indian study done by Vijayaselvi et al. in 2015.
GAD-7 was performed as an initial screening tool for GAD in the present study where moderate level of anxiety was common in pregnant women, and majority of nonpregnant women had minimal anxiety. GAD-7 mean score among pregnant women was 5.5. Kakaraparthi et al. did a study on the same, which showed higher scores in the pandemic era (5.24) when compared to prepandemic era (11).
In a similar study by Jyoti Kantipudi et al. from South India, 23% of pregnant women had GAD which is similar to the present study findings.
In a study done by Naja et al. in Qatar in the prepandemic era (2018–2019), 26.5% of their study population reported high pregnancy-related anxiety, which is higher than the present study anxiety level.
In the present study, health and disability evaluated by the WHO DAS 2.0 scoring system showed higher prevalence of disability among pregnant women than nonpregnant. In the present study, there was a mild-to-moderate positive correlation between Perceived Stress Scale score with anxiety (GAD-7 score) and disability (DAS 2.0 score), which states that the more they take the stress, the more they will go into anxiety and disability.
Practice of COVID preventive measures among both the groups was above the accepted levels. Although pregnant women had more history of going into crowds, they were following COVID appropriate behavior (mask, social distancing etc.).
The present study was done only in the pandemic era, with no comparative data of prepandemic period. As the entire study population was restricted to one urban health center and limited to people availing government services, pregnant women utilizing private health services were missed out. The findings of the study can be generalized to urban slums, which is our core study population but not to rural population.
| Conclusion|| |
The present study showed pregnant women of the pandemic era had higher PSS, GAD-7, and DAS 2.0 mean score when compared to nonpregnant women. Both the groups had good preventive knowledge and practice regarding COVID-19 preventive measures.
Recommendations: Pregnancy is already a state of stress and anxiety for the mother, so there should be more focus on provision of mental health-care services as a part and partial of the existing maternal and child health services to achieve the overall goal of Universal Health Coverage. Health-care providers, especially doctors, ANM, and ASHA workers should be trained to give counseling to reduce overall stress and anxiety.
I would like to thank my HOD Dr. Kenche Bhavani and my professor Dr. Syed Ahmed for helping and guiding me to complete the project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Community Medicine, Osmania Medical College, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]