Pandemic-related pregnancy stress and anxiety among women pregnant during the coronavirus disease 2019 pandemic

Abstract

Prenatal maternal stress and anxiety, whether at times of disaster or not, are well-established risk factors for preterm birth, low birthweight, and infant health problems and may have long-lasting effects on the offspring.1Harville E.W. Xiong X. Buekens P. Disasters and perinatal health: a systematic review.Obstet Gynecol Surv. 2010; 65: 713-728Crossref PubMed Scopus (184) Google Scholar,2Ibrahim S.M. Lobel M. Conceptualization, measurement, and effects of pregnancy-specific stress: review of research using the original and revised prenatal distress questionnaire.J Behav Med. 2020; 43: 16-33Crossref Scopus (46) Google Scholar Approximately 21% to 25% of women experience prenatal anxiety symptoms (eg, excessive worry, nervousness, agitation). Policies to decrease the spread of the novel coronavirus disease 2019 (COVID-19) by sheltering in place and social distancing and increases in unemployment, poverty, and intimate partner violence have dramatically changed the daily lives of pregnant women and presumably heightened maternal stress and subsequent anxiety.3Saccone G. Florio A. Aiello F. et al.Psychological impact of coronavirus disease 2019 in pregnant women.Am J Obstet Gynecol. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (202) Google Scholar The COVID-19 pandemic has created an urgent need to examine the extent to which pandemic-related stress predicts heightened anxiety in women pregnant during this crisis. At the end of April 2020, 788 pregnant women were recruited through social media to complete an online questionnaire. Study inclusion criteria were being pregnant at the time of questionnaire completion and older than 18 years. Exclusion was inability to read or write English. The study was approved by the Institutional Review Board of Stony Brook University. The questionnaire included sociodemographic factors (maternal age, ethnicity and race, financial status, health insurance, lifetime experience of emotional or physical abuse), current use of psychiatric medications, obstetrical factors (parity, gestational age, pregnancy risk, chronic medical conditions, planned pregnancy, fertility treatments), prenatal behaviors (eg, vitamins, exercise, enough sleep), alterations to prenatal care appointments (cancellation or rescheduling owing to COVID-19), and anxiety (generalized anxiety disorder-7 [GAD-7] with the following clinical cutoff values: 0–4, no to minimal; 5–9, mild; 10–14, moderate; and 15–21, severe). COVID-19-related concerns were assessed using the pandemic-related pregnancy stress (PREPS) scale, a novel instrument developed by our research team.4Preis H, Inman E, & Lobel M. Contribution of psychology to research, treatment, and care of pregnant women with opioid use disorder. American Psychologist 2020. https://doi.org/10.1037/amp0000675.Google Scholar Exploratory factor analysis on a random half of the sample confirmed its 3 constituent factors as follows: preparedness stress (7 items; eg, “I am worried I will not be able to have someone with me during the delivery”), perinatal infection stress (5 items; eg, “I am worried that my baby could get COVID-19 at the hospital after birth”), and positive appraisal (3 items; not relevant to this study). Confirmatory factor analysis on the second half of the sample indicated good model fit as follows: comparative fit index, 0.93; Tucker-Lewis index, 0.92; root mean square error of approximation, 0.076; and standardized root mean square residual, 0.079. Stress scales were internally consistent (Cronbach’s α>0.80). We used hierarchical binary logistic regression to predict odds risk for minimal or mild anxiety vs moderate or severe anxiety. Participants were on average aged 29.2±5.3 years and their average gestational age was 25.3±9.1 weeks. Approximately three-quarters were white and non-Hispanic (n=608, 77.2%); almost half were primiparas (n=362, 45.9%). A total of 166 women (21.1%) reported no to minimal anxiety symptoms (GAD-7=0–4), 280 (35.6%) reported mild anxiety symptoms (GAD-7=5–9), 170 (21.6%) reported moderate anxiety symptoms (GAD-7=10–14), and 171 (21.7%) reported severe anxiety symptoms (GAD-7≥15). Logistic regression predicted moderate or severe anxiety from all sociodemographic and obstetrical background variables and the 2 PREPS scales (Table). The first step included sociodemographic variables (R2=0.07) and the second step included medical and obstetrical variables (ΔR2=0.09). The last step included all previous variables as confounders and added the 2 PREPS scales (ΔR2=0.12). In the final model (total R2=0.28), abuse history, high-risk pregnancy, preparedness stress, and perinatal infection stress all independently predicted greater likelihood of moderate or severe anxiety. Older maternal age and better prenatal health behaviors were protective against anxiety.TableBinary multivariate hierarchical logistic regression predicting moderate or severe anxiety symptoms (n=788)Step 1Step 2Step 3aOR95% CIaOR95% CIaOR95% CIOlder maternal age0.54bP<.010.36–0.810.39cP<.0010.24–0.610.46bP<.010.28–0.74Racial and ethnic minority0.910.64–1.290.970.67–1.411.240.83–1.85Married or cohabiting0.760.49–1.160.710.45–1.130.750.46–1.22Financial insecurity1.130.78–1.640.910.61–1.350.860.56–1.30Abuse history2.06cP<.0011.44–2.951.82bP<.011.25–2.661.85bP<.011.24–2.75Private insurance0.790.55–1.40.780.53–1.160.820.53–1.25Primipara1.070.77–1.471.250.89–1.77Gestational age1.000.99–1.021.000.98–1.01Planned pregnancy1.110.78–1.591.210.83–1.77Fertility treatment0.830.48–1.450.790.44–1.43Chronic illness1.290.91–1.841.180.82–1.72High riskdWomen who reported being high risk and those who were unsure were grouped together.1.79bP<.011.27–2.531.52aP<.051.06–2.19Healthy behaviors0.64cP<.0010.54–0.750.65cP<.0010.54–0.78Appointment altered1.49aP<.051.09–2.021.120.81–1.56Psychiatric medication0.860.50–1.460.740.42–1.31PREPS scale—preparedness1.75cP<.0011.35–2.26PREPS scale—infection1.55cP<.0011.28–1.88R2=0.07R2=0.16R2=0.28aOR, adjusted odds ratio; CI, confidence interval; PREPS, pandemic-related pregnancy stress.Preis et al. Pandemic-related pregnancy stress and anxiety. AJOG MFM 2020.a P<.05b P<.01c P<.001d Women who reported being high risk and those who were unsure were grouped together. Open table in a new tab aOR, adjusted odds ratio; CI, confidence interval; PREPS, pandemic-related pregnancy stress. Preis et al. Pandemic-related pregnancy stress and anxiety. AJOG MFM 2020. Pregnant women during the COVID-19 pandemic experienced substantial anxiety as indicated by the high prevalence of mild, moderate, and severe anxiety in this sample. Stress related to preparation for birth during the pandemic and worries about COVID-19 infection to self and the baby can elevate women’s risk of experiencing moderate or severe anxiety over and above sociodemographic, obstetrical, and other health relevant factors.