COVID-19 is the abbreviation for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Primarily documented as ‘pneumonia of an unknown cause’ (World Health Organization, 2020), the COVID-19 outbreak was declared a pandemic in early March 2020. This announcement caused governing bodies to classify those with underlying health issues as being ‘at risk,’ essentially meaning more susceptible to adverse outcomes following infection. Initially in the UK, only ‘women who are pregnant with significant heart disease, congenital or acquired’ (UK Government, 2020a) were considered at risk. Following this, all pregnant women were categorised as being at risk (Alszewski, 2020). This did not mean that there was evidence to suggest that COVID-19 is any more contractible during pregnancy. The decision was made as a precautionary measure as pregnancy can alter the physiological response to severe viral infections (Royal College of Obstetricians and Gynaecologists, 2020).
There is currently minimal research surrounding COVID-19 and pregnancy. As of February 2020, research by Liu et al (2020) found no evidence to support vertical transmission of COVID-19 from mother to baby. An analysis of 38 pregnant women and their pregnancy outcomes evidenced no confirmed cases of intrauterine transmission from mothers with COVID-19 to their foetuses (Schwartz, 2020). Conversely, in June, a case study by Alzamora et al (2020) reported a severe maternal case of COVID-19 where the baby presented as positive when tested, suggesting the possibility of vertical transmission. A recent systematic review and meta-analysis has reported that pregnancies where the mother is positive for COVID-19 are associated with elevated occurrences of miscarriage, preterm birth and perinatal death (Di Mascio et al, 2020).
Due to the novelty of the virus, research infancy and the overall uncertainty of the effects, many healthcare settings globally have shifted to disallow the presence of birthing partners during labour to adhere to social distancing guidelines and to minimise the risk of COVID-19 transmission. Pregnant women have seen their original birth plans shelved due to closures of midwife-led birthing centres, minimisation to routine appointments and scans, and delays and cancellations in caesarean sections (Brewer, 2020).
Pregnancy and anxiety
Pregnancy is an occurrence which can be synonymous with anxieties and concerns (Rathbone and Prescott, 2019). Research suggests pregnant women are three times more likely to develop anxiety or an anxiety related disorder specific to pregnancy (Stoll et al, 2018). Pregnancy specific anxiety is defined by apprehensions and uncertainties felt about being pregnant, childbirth, child health and the aptitude to parent (Huizinket al, 2004). Previous studies have evidenced that moderate and severe levels of anxiety are more prevalent in pregnant women than non-pregnant (Shagufta and Shams, 2019). One study (n=500) found that pregnant women in their third trimester and nulliparous women presented with the highest prevalence of pregnancy specific anxiety (Madhavanprabhakaran et al, 2015).
As a precautionary measure, in May 2020, pregnant women were advised to shield (Dashraath et al, 2020). In adherence with social distancing guidelines (UK Government, 2020b), hospitals immediately began to carry out routine maternity appointments remotely (NHS, 2020). Simultaneously, the presence of a birthing partner was banned across the majority of hospitals and Trusts. With current recommendations for pregnant women and the alterations to maternity services, it is logical to assume that the levels of general anxiety and health anxiety during pregnancy will increase. This could be due to parity, gravidity, reduced communication with healthcare professionals or the virus itself.
Objective
The objective of this research is to explore current actual, and perceived, levels of generalised anxiety disorder and health anxiety in pregnant women during the COVID-19 outbreak.
Method
Design
This study used a quantitative design which analysed clinically diagnosed and self-reported general and health anxiety levels and predictors of said anxieties.
Recruitment
Due to the social distancing and self-isolation policies the questionnaire was disseminated online. Social media platforms such as Facebook and Twitter were utilised to share the study. The questionnaire was posted on Twitter. Twitter analytics shows that the tweet made 3 592 impressions, was engaged with 190 times and had 13 retweets. The questionnaire was disseminated in Facebook support groups for mothers and mothers-to-be. Table 1 displays the name of the Facebook group, the total amount of members and the total amount of posts made within the groups over the past month.
Table 1. Facebook group, total member and posts (past month)
| Facebook group | Total members | (#) Posts (past month) |
|---|---|---|
| Family lockdown tips and ideas | 1 139 391 | 4 3132 |
| Believe in rainbows | 122 012 | 3 756 |
| Mums chat and advice | 31 183 | 4 652 |
| Expectant, new and nursing mothers | 30 552 | 92 |
| Pregnant during the COVID-19 pandemic | 23 819 | 5 152 |
| Dads, mums, jelly tums and changing bums | 23 741 | 2 900 |
| Mummies and mummies to bee | 16 030 | 1 000 |
| Mothers meeting | 13 429 | 1 144 |
| Mums, mams and mothers | 7 254 | 5 328 |
| Mummy and mummy to be advice corner | 6 610 | 760 |
| Mommies expecting and forever | 3 511 | |
| Mental health awareness | 3 375 | 68 |
| Anxiety during and after pregnancy | 2 130 | 100 |
| Mummy and pregnancy advice | 1 327 | 692 |
| Parent advice chat and fun and play date | 837 | 4 |
| Pregnancy support during COVID-19 | 564 | 0 |
| Expectant, new and experienced mums | 359 | 104 |
| Pregnancy and postnatal support and camaraderie during COVID-19 | 100 | 4 |
| Pregnancy support in Michiana during COVID-19 | 94 | 12 |
| Pregnancy talk and health tips | Inaccessible | Inaccessible |
| BABY BOOM IN OPM. | Inaccessible | Inaccessible |
| For expectant mothers and pregnant mothers | Inaccessible | Inaccessible |
| New moms, moms-to-be, and experienced moms | Inaccessible | Inaccessible |
One administrator explained that her group was in its infancy and therefore may not reach optimum engagement. The administrator of one support group decided not to post the research due to being inundated with similar requests.
Organisations such as National Childbirth Trust (NCT), Mumsnet, BabyCentre and Child.org were approached to share the questionnaire on their platforms. The NCT replied and stated that they could not share the research at that moment in time. No replies were received from Mumsnet, BabyCentre and Child.org.
Participants
Overall, there were 674 female participants in this study. Of the sample, eight were aged 16–20 years old (1.2%), 107 were aged 21–25 years old (15.9%), 267 were aged 26–30 years old (39.6%), 243 were aged 31–35 years old (36.1%), 45 were aged 36–40 years old (6.7%), and four were aged 41–45 years old (0.6%). There were 102 participants (15.1%) from the UK, 535 (79.4%) from the US and 10 (1.5%) from Australia. The remaining 3.9% (n=27) were from Europe, Africa, Asia, the Pacific Islands or did not specify.
Materials
For the current study, participants were asked general demographic questions such as age, location and marital status. They further gave information related to their pregnancy, such as whether their current pregnancy was their first one, what trimester they were currently in and whether they had any children outside of their current pregnancy. Participants then completed the generalised anxiety disorder-seven (GAD-7), a brief, seven-item measure to assess generalised anxiety disorder (Spitzer et al, 2006). When scoring GAD-7 responses, scores of five, 10 and 15 are used for the cut-off points of mild, moderate and severe anxiety, respectively.
Following this, participants completed the initial 14 questions of the Health Anxiety Inventory (HAI-18). Only the first 14 questions were used as only these items effectively score anxiety (Salkovskis et al, 2002). Each item was scored 0–3, with zero being the lowest and three indicating higher levels. Scores of 14, 28 and 42 were used for the cut-off points of mild, moderate and severe health anxiety, respectively. Following each measure, participants were asked to self-report any perceived changes in general anxiety or health anxiety considering COVID-19.
In regards to the measures used, when measuring pregnancy specific anxiety, the most frequently used is the State-Trait Anxiety Inventory (STAI) (Newham et al, 2012; Tendais et al, 2014; García González et al; 2018; Gimbel et al, 2020). However, the GAD-7 has also proven to be a valid screening tool for generalised anxiety disorder in pregnancy and the postpartum period (Simpson et al, 2014) and is being used more frequently during pregnancy (Krusche et al, 2019; Kotabagi et al, 2020). The HAI-18 was used as the measure is recommended by the NHS Improving Access to Psychological Therapies (IAPT) (Aazh and Moore, 2017).
Procedure
The questionnaire was disseminated online via social media platforms. As Twitter is an open platform, it was posted and retweeted publicly. However, the Facebook support groups were closed which meant that only members of the groups had access to information posted. Prior to posting the study in the closed groups, administrators were contacted. Only when permission was granted did the researchers post the questionnaire. Organisations were contacted using the same method. Following this, the participants used the anonymous link, which led them to the questionnaire on Qualtrics. The questionnaire was live from 30 March 2020 to 3 April 2020.
Data analysis
The study initially explored the descriptive statistics, then analysed the results from the GAD-7 and HAI, and following pregnancy related questions using IBM SPSS Statistics 23.
Ethics
This study was given ethical approval by the University of Bolton's ethics committee in March 2020. All participants gave their consent for use of their data in this study on the proviso that no identifiers were included. Participants were provided with a check box to tick to confirm their consent.
Results
Data handling
Initially, there were 804 responses to the survey. Participants' IP addresses were used only to identify and remove duplicates. When further exploring the data, it was found that 122 participants had not completed the quantitative or the qualitative aspects of the survey. Therefore, these results could not be analysed and were removed from the data set. This is evidenced in Figure 1.
Figure 1. Response exclusion flow chart
Descriptive statistics
Overall, 39.5% (n=266) of participants were experiencing their first pregnancy, while the rest (n=408, 60.5%) had been pregnant previously. Of the women, 50 (7.4%) were in the first trimester, 286 (42.4%) were in the second trimester, and 338 (50.1%) were in the third trimester of pregnancy. Of the participants, 381 (56.5%) had children besides their current pregnancy, whereas 293 (43.5%) did not. Most participants (91.2%, n=615) were married or in domestic partnerships. There were 49 (7.3%) single, four (0.6%) were divorced, three (0.4%) were separated and three (0.4%) preferred not to specify their marital status.
Complications
Of the sample, 21.4% confirmed they were experiencing complications within their current pregnancy. These complications concerned both the mother and the child. Of the women, five stated that they had been classed as high risk due to experiencing a multiple pregnancy of either twins or triplets. Gestational diabetes (n=31), bleeding (n=18), hyperemesis gravidarum (n=15) and fluctuating blood pressure (n=10), were some of the most frequently reported complications. Of the women, nine reported that their current pregnancy was a result of in vitro fertilisation.
Regarding previous pregnancies, 30.4% reported having experienced complications. The majority of these appeared to occur later in the pregnancy. Miscarriage (n=59), pre-eclampsia (n=25), gestational diabetes (n=19), pre-term labour (n=19) and pregnancies which resulted in still born (n=4) were the most frequently reported previous complications.
General and health anxiety
In this study, when referring to clinical diagnosis, these are the diagnoses a participant has been given previously by their personal healthcare professionals independent to the research.
Results show that of the 674 participants, 198 (29.4%) reported that they have been clinically diagnosed with GAD and a further 240 (35.6%) consider themselves to experience GAD but do not have a clinical diagnosis. With health anxiety (HA), four (0.6%) reported that they have a clinical diagnosis, and 36 (5.3%) consider themselves to experience it but do not have a clinical diagnosis.
Of the 674 participants, 167 (24.8%) experienced mild general anxiety, 235 (34.9%) experienced moderate general anxiety and 272 (40.4%) experienced severe general anxiety. Of the same participants, 302 (44.8%) experienced mild health anxiety, 326 (48.4%) experienced moderate health anxiety and 46 (6.8%) experienced severe health anxiety.
Predictors
To explore significant predictors of pregnancy related GAD and HA during the pandemic, two multiple regression analyses were performed using general and pregnancy related demographics. Such demographics were age, location, marital status, nulliparous/multiparous status, trimester, current pregnancy complications, previous pregnancy complications and the presences of other offspring.
The first model explored significant predicators of GAD during pregnancy. The r square is 0.027 (adjusted R2=0.015). The analysis of variance (ANOVA) shows a significant effect of three of the variables on general anxiety disorder during pregnancy; (f(8, 665)=2.29, p<0.05).
Table 3 shows that the factors which are significant in predicting GAD in pregnancy are; age (B=-0.086, t=-2.18, p=0.029), complications in the current pregnancy (B=-1.49, t=-1.97, p=0.049) and complications in previous pregnancies (B=-.18, t=-2.43, p=0.015). All other factors are non-significant.
Table 2. Clinical diagnosis and self-reports
| Clinically diagnosed n (%) | Self-reported prevalence n (%) | |
|---|---|---|
| Generalised anxiety disorder (GAD) | 198 (29.4) | 240 (35.6) |
| Health anxiety (HA) | 4 (0.6) | 36 (5.3) |
| Illness anxiety disorder (IAD) | 1 (0.1) | 4 (0.6) |
| Somatic symptom disorder (SSD) | 2 (0.3) | 1 (0.1) |
Table 3. Generalised anxiety disorder coefficients
| Model | Unstandardised | Standardised | t | Sig | |
|---|---|---|---|---|---|
| B | Std error | Beta | |||
| How old are you? | -0.077 | 0.035 | -0.086 | -2.183 | 0.029 |
| Where are you currently located? | 0.009 | 0.022 | 0.016 | 0.419 | 0.676 |
| What is your marital status? | 0.022 | 0.067 | 0.012 | 0.320 | 0.749 |
| Is this your first pregnancy? | -0.016 | 0.152 | -0.010 | -0.104 | 0.917 |
| What trimester of your pregnancy are you in? | 0.049 | 0.049 | 0.039 | 1.011 | 0.312 |
| Have you had/do you have any complications in your current pregnancy? | -0.149 | 0.076 | -0.077 | -1.970 | 0.049 |
| Have you had any complications in a previous pregnancy? | -0.183 | 0.075 | -0.106 | -2.431 | 0.015 |
| Do you have children besides your current pregnancy? | 0.029 | 0.142 | 0.018 | 0.205 | 0.838 |
The second model explored significant predicators of health anxiety during pregnancy. The r square is 0.029 (adjusted R2=0.017). The analysis of variance (ANOVA) again, shows a significant effect of two of the aforementioned variables on health anxiety during pregnancy; (f(8, 665)=2.46, p<0.05).
Table 4 shows that the factors which are significant in predicting HA in pregnancy are trimester of pregnancy (B=-0.08, t=-1.99, p=.047) and complications in the current pregnancy (B=-1.46, t=-2.52, p=0.012). All other factors are non-significant.
Table 4. Health anxiety coefficients
| Model | Unstandardised | Standardised | t | Sig | |
|---|---|---|---|---|---|
| B | Std error | Beta | |||
| How old are you? | 0.001 | 0.027 | 0.001 | 0.029 | 0.977 |
| Where are you currently located? | 0.003 | 0.017 | 0.007 | 0.172 | 0.864 |
| What is your marital status? | -0.004 | 0.052 | -0.003 | -0.079 | 0.937 |
| Is this your first pregnancy? | -0.064 | 0.117 | -0.052 | -0.550 | 0.583 |
| What trimester of your pregnancy are you in? | -0.075 | 0.037 | -0.077 | -1.992 | 0.047* |
| Have you had/do you have any complications in your current pregnancy? | -0.146 | 0.058 | -0.099 | -2.519 | 0.012* |
| Have you had any complications in a previous pregnancy? | -0.092 | 0.058 | -0.070 | -1.595 | 0.111 |
| Do you have children besides your current pregnancy? | 0.074 | 0.109 | 0.060 | 0.676 | 0.499 |
COVID-19
Of 674 participants, three (0.4%) reported that they had been diagnosed with COVID-19, 27 (4%) reported that they were displaying the typical symptoms of COVID-19 (persistent cough and high temperature), 47 (7%) reported that they had been in direct contact of someone who has displayed symptoms or been diagnosed with COVID-19 and 131 (19.4%) reported that they had had indirect contact with someone who has displayed symptoms or been diagnosed with COVID-19 (Table 5).
Table 5. COVID-19 exposure
| n (%) | |
|---|---|
| Clinically diagnosed | 3 (0.4) |
| Displaying typical symptoms | 27 (4.0) |
| Direct contact (with someone diagnosed with COVID) | 47 (7.0) |
| Indirect contact (with someone diagnosed with COVID) | 131 (19.4) |
As evidenced in Table 6, most participants self-reported that COVID-19 had increased their general anxiety; 475 strongly agreed (70.5%), and 158 somewhat agreed (23.5%). The remaining participants either, neither agreed nor disagreed, or somewhat and strongly disagreed.
Table 6. Self-reported increases to generalised anxiety disorder and health anxiety due to COVID-19 (n (%))
| Strongly agree | Somewhat agree | Neither agree nor disagree | Disagree | Strongly disagree | |
|---|---|---|---|---|---|
| Generalised anxiety disorder | 475 (70.5) | 158 (23.5) | 11 (1.6) | 8 (1.2) | 17 (2.5) |
| Health anxiety | 393 (58.3) | 214 (31.8) | 28 (4.2) | 19 (2.8) | 10 (1.5) |
The results for self-reports of increased levels of HA since COVID-19 were similar; 393 (58.3%) strongly agreed, and 214 (31.8%) somewhat agreed. The remaining participants either, neither agreed nor disagreed, or somewhat and strongly disagreed.
Discussion
Overall, this study has explored the clinically diagnosed and self-reported levels of general and health anxiety levels and predictors of said anxieties.
Varying levels of anxiety is a typical occurrence during pregnancy (Prescott and Mackie, 2017; Rathbone and Prescott, 2019). There were significantly more women who self-reported experience of GAD than were diagnosed. This was also true for HA. There were low reports of clinical diagnoses of HA; however, pregnant women self-reported increased levels of anxiety and HA due to the COVID-19 outbreak. To refer to the limitations section, although participants reported such anxiety increases during the pandemic, it cannot be claimed that COVID-19 is the sole cause due to lack of previous comparable data.
Results evidenced that three significant predictors of GAD during pregnancy were age, complications in the current pregnancy and complications in previous pregnancies. Age being a significant predicator of GAD during pregnancy can be considered on a spectrum. Younger ages may suggest inexperience and older may indicate anxieties concerning being of an advanced maternal age. Complications in current and previous pregnancies increase anxieties due to negative past or present experience of atypical occurrences.
Results also evidenced that trimester of pregnancy and complications in the current pregnancy were both significant predictors of health anxiety during pregnancy. The first trimester and the last trimester pose risks such as higher prevalence of miscarriage and birthing complications, respectively. Complications during current pregnancies increase anxiety as concerns are present and ongoing.
It may be inferred that the COVID-19 outbreak has become a trigger for novel pregnancy anxieties which stem from the typical. For example, subtle lifestyle alterations are suggested by healthcare professionals when pregnant such as ensuring a healthier diet, avoiding strenuous activity, and taking care of one's mental health. However, receiving governmental recommendations to self-isolate may have caused an increase in general anxiety due to changes in routine and loneliness. It is feasible that there has been an increase in HA in pregnant women due to exposure to the virus itself, instigating concern for the mother and child. Pregnant women, having become more and more active patients in their own healthcare over the years, may now be anxious about changes in the care they will receive during the expectant and childbirth phases of pregnancy, especially when there is a need to scale back routine monitoring. Many pregnant women rely on routine monitoring to assure that their child is typically developing, ask any questions they have and allay their concerns. Decreased access to these appointments may lead to increased levels of anxiety as the women no longer have access to the typical reassurances from healthcare professionals.
However, it is important to reiterate that with no comparative data, the results to this study cannot be deemed conclusive.
Recommendations
While research supports the fact that the COVID-19 outbreak has increased maternal anxieties (Mappa et al, 2020), this manuscript can only speculate as participants were not asked to report the reasons for their increased general and health anxiety. Further research would benefit from identifying the cause. This information would be advantageous to both healthcare settings and government bodies as they may inform further recommendations for, and alterations to, pre- and postnatal healthcare. It is also recommended that assurances are put into place where possible for pregnant women, such as clear information and consistent communication strategies.
Limitations
Although the pregnant women who participated in this study self-reported increases in GAD and HA due to the COVID-19 outbreak, it is salient to note that this cannot definitively evidence that COVID-19 is the causal factor of increased GAD and HA during pregnancy. This is due to the fact that there is no comparative research data, collated prior to the outbreak which this study's results can be equated to.
Conclusion
In conclusion, the COVID-19 outbreak has caused increased self-reported, perceived levels of GAD and HA in pregnant women. The exact reasons for self-reported increases should be investigated. Changing information as the pandemic continues will inevitably continue to affect GAD and HA in pregnant women. Healthcare providers should therefore consider their strategies for communication of information, appointments, and general care of pregnant women as government guidelines are continually changing.
Key points
- Pregnancy can be an anxiety inducing experience
- Pregnant women were initially classed as a high-risk demographic
- Government classifications of and recommendations to pregnant women have caused increased occurrences of generalised anxiety disorder and health anxiety
- Prenatal and perinatal healthcare has altered due to the COVID-19 outbreak
- To decrease levels of generalised anxiety disorder and health anxiety during pregnancy, where safe to do so, routine appointments should remain, and nonclinical support should be allowed
CPD reflective questions
- Have you identified increased anxiety in pregnant women in practise?
- Does there need to be differentiation between health anxiety and COVID-19-triggered health anxiety?
- How may we decrease levels of general anxiety disorder and health anxiety in pregnant women throughout the pandemic?