Pregnant Women’s Well-being and Worry During the COVID-19 Pandemic: A Comparative Study

Background: COVID-19 caused some worries among pregnant women. Worries during pregnancy can affect women’s well-being. We investigated worry and well-being and associated factors among pregnant women during the COVID-19 epidemic. Methods: This descriptive cross-sectional study was conducted on 484 pregnant women using an online questionnaire. Sampling was performed in a period between May 5 and Aug 5, 2020. Inclusion criteria were having a single healthy fetus and having no signi�cant psychological disorder. We collected the data using the Persian versions of the World Health Organization's well-being Index (WHO-5 well-being index) and the Cambridge worry scale. Results: The mean total scores of the WHO-5 well-being index and the rate of WHO-5 score < 50 were 64.9 ± 29.0 and 24.4%, respectively. Predictors of women’s worry are the increased level of fear of COVID-19, a low family income, employment situation, nulliparity, and having no close family member with chronic disease (p < 0.05). The results of logistic regression analysis on well-being scores showed that the worry about fetus health (OR = 1.081, p = 0.005), women’s own health and relationships (OR = 1.055, p = 0.047), and having an infected person with COVID-19 among relatives (OR = 2.095, p = 0.039) could predict the well-being in pregnant women. The mean score of worry about fetus health in the current study was lower than that of the previous study (p = 0.024). The mean score of socio-economic worry in the current study was higher than that of the previous cross-sectional study (p = 0.025). The result indicates that the percentage of participants with a low level of well-being did not differ by the two periods under study (chi-square = 0.099, p = 0.753) (table 7). Conclusions: The percentage of women experiencing a low well-being state was relatively high. This result is worthy of attention by health care providers and policy makers. To decrease women’s socio economic concerns, governments and charities should expand programs providing �nancial support to pregnant


Background
Pregnancy has been described as one of the most pleasant and critical periods in the most women's lives which involves new emotions and experiences.Unfortunately, since the COVID-19 epidemic, pregnancy and childbirth for women are taking place in di cult conditions.Several issues have contributed to increasing concerns among people and in particular in pregnant women including the stressful news of the number of infected individuals and the death toll, the diverse symptoms and complications caused by the disease [1], and the spreading of 'fake news' and con icting information on social networks [2].
Iran is among the countries that has been severely affected by this Pandemic.In addition to concerns about COVID-19 disease, severe economic problems stemming from sanctions imposed on the country have had very harmful effects on the livelihood of the people [3].
Pregnant women have been severely affected by previous epidemics [4]; so, some researchers predicted that COVID-19 might have similar impact on pregnant women.So far, many questions relating to COVID-19 in pregnant women remain without clear and satisfactory answers.These include questions about the probability of the increased risk of getting COVID-19 or presenting severe complications, the possibility of women-to-child transmission, the effect of COVID-19 on the fetus, the best childbirth method, and the risk of death in infected pregnant women [4].The level of anxiety and fear among pregnant women increased during the COVID-19 pandemic.This is attributable to a number of factors including, the adverse effects of the disease on pregnant women, the uncertainty about the effectiveness of the available treatments and timely vaccine production, and our limited knowledge about the disease [5].
Under normal circumstances, 80% of women's main concerns about pregnancy and childbirth are nothing extraordinary and unusual.Only about 20% of pregnant women experience excessive concern about future events in pregnancy [6].A study on Indian obstetricians showed that during COVID-19 pandemic the level of fear and worry were increased in pregnant women [7].Fear, worry, and anxiety during pregnancy has negative physical and psychological health consequences for pregnant women.Previous studies suggest that pregnancy stress may lead to mother-infant relationship disorder, antenatal and postpartum depression, increased physical problems [8,9] and an increased risk of pre-eclampsia [10].
Rashidi and his colleague have reported an increased preference for cesarean during the COVID-19 epidemic in Tehran [11].
In addition to worry about COVID-19, pregnancy brings speci c worries to women.COVID-19 related worries may elevate some pregnancy speci c worries such as worry about fetus health or mother's own health and worry about going to hospital.Several studies have attempted to understand the nature of worries in pregnant women and have developed scales to measure the nature and the extent of pregnant women's worries.Results of these studies indicate that pregnant women's worries originate from different sources.These sources can be classi ed as socio-medical, socio-economic, the health of the fetus, mother's own health and relational issues [12,13].
Well-being is considered to consist of two components: feeling healthy and relatively robust and being able to carry out ones job and other tasks satisfactorily.There are two sides to wellbeing: a psychological and an emotional one [14,15].Psychological well-being involve re exive consideration and appraisals of one's own life.Emotional well-being is more a matter experiencing positive and life enhancing emotions such as security, joy and contentment [16].The World Health Organization-5 Well-Being Index (WHO-5) has been developed to screen for depressive symptoms.It has been also used to monitor emotional wellbeing and psychological well-being [17].
With regard to the stress and concerns of pregnant women that were reported above, we wanted to explore the extent that these concerns and fears had negative effect on maternal wellbeing.Therefore, the aim of this study is to investigate wellbeing of pregnant women and its associated factors during the COVID-19 epidemic.We also aimed to compare well-being and worries during this period with those reported in studies conducted before the pandemic.

Methods
We conducted this descriptive cross-sectional study on pregnant women who were registered in health centers a liated to Sabzevar University of Medical Sciences during the COVID-19 pandemic.We collected the data using an online questionnaire.Midwives working in health centers a liated to Sabzevar University of Medical Sciences used text messages to invite pregnant women registered with them to participate in the study.Those who responded to the invitation received an informed consent form, and then were provided with the link for the online questionnaire.Furthermore, we invited the participants in virtual childbirth preparatory classes to participate in the study.Overall, 484 women responded to the invitation and participated in the study.Sampling was performed between May 5 and Aug 5, 2020.
Inclusion criteria were being pregnant at the time of the study, having a single healthy fetus, informed consent to participate in the study, and having no signi cant psychological disorder.To determine the sample size, we considered the percentage of women in a previous study whose worry score was less than 38.5 (the mean score of the worry scale) [13] and also the percentage of women in another study whose well-being score was less than 50 [18].These percentages were 45% and 34.5%, respectively.We calculated the sample size using Cochran's formula (pqz2/d2) with the con dence level of 95% and a margin of error of 5%.The minimum sample size estimate is 347.We collected the data using the Persian versions of the WHO-5 well-being index [18] and the Cambridge worry scale (CWS) [13].In addition, we developed a questionnaire to investigate socio-demographic and obstetric information (supplementary le).

Instruments
We collected the data on maternal socio-demographic and obstetric information (such as age, level of education, employment status, monthly family income, gestational age, parity, having a chronic disease or pregnancy complication, having at least one COVID-19 infected person in their relatives, and having at least one death due to COVID-19 in relatives).To measure the fear of COVID-19, we designed one question with a likert-type scale ranging from "not at all" (1) to "severe" (5) and asked women to rate their fear (supplementary le).

Cambridge worry scale (CWS)
Green and colleagues developed the Cambridge worry scale (CWS) with 17 items [12] to measure worry content among individuals.Scores are ranged from "not a worry" (0) to "major worry" (5).The total score of the CWS ranges from zero to 85, with a higher score representing the severity of worries.The CWS includes four subscales as follow: socio-medical, own health, socio-economic, and relational.The reliability of the CWS was aceptable (Cronbach's alpha = 0.76).We translated the scale into Persian and con rmed its validity among pregnant women.The Persian version consists of 23 items and 4 factors including the socio medical (10 item)( such as "Having nobody in delivery ward", "Giving birth", "Whether midwives provide good care in labor", "Going to hospital", "Crowded delivery ward"), health of mother/other & Relationships (4 items)( i.e., "Your own health", "The health of someone closes to you", "Your relationship with your husband", "Your relationship with your family and friends"), fetus health (3 items)( i.e., "The possibility of miscarriage", "The possibility of fetal death, disease or anomaly", "The probability of going into labor too early") and socio-demographic factor (6 items)(such as "Money problems", "Employment problems").The Cronbach's alpha value for the 23 items of the Persian CWS was 0.886 [13].We used the Persian version of the CWS for investigating pregnant women's worries during the COVID-19 pandemic because we believe its items are relevant to the pregnant women's worries during the pandemic.
The World Health Organization's well-being Index (WHO-5 well-being index) The World Health Organization's well-being Index (WHO-5 well-being index) was designed to assess the well-being of individuals over the past two weeks [19].It consists of ve positively worded items with a 6point Likert scale (such as "I have felt cheerful and in good spirits").Each item is rated from zero to ve.

Data Analysis
We analyzed the data using SPSS software (SPSS Inc.Released 2009.PASW Statistics for Windows, Version 18.0.Chicago: SPSS Inc.).We used chi-square test of independence to investigate the relationships between categorical variables.We used t-test to compare the mean scores of the Cambridge worry factors classi ed according to the levels of the WHO-5 well-being scores and also according to the dichotomous socio-demographic and obstetric variables.
We used analysis of variance for comparing the mean scores of the CWS in three categories in each of the following variables: gestational age, income level, and education level.We performed binary univariate logistic regressions analyses using the backward-LR method to investigate if there are signi cant associations between socio-demographic/obstetric variables and the levels of WHO-5 wellbeing scores.Then, we entered all seven statistically signi cant variables into a multiple logistic regression analysis to reveal predictors of the well-being in pregnant women.We performed multiple linear regression analysis using the stepwise method to investigate predictors of the worry in pregnant women.We entered all variables with p<0.25 into the multiple regression analysis.We used t-test to compare well-being and worry in pregnant women during the COVID-19 pandemic with the previous crosssectional studies which were conducted on pregnant women in 2016 and 2019.

Results
This descriptive cross-sectional study was conducted on 484 pregnant women participated in the study between May 5 and Aug 5, 2020.Table 1 shows the characteristics of the participating samples.The mean age, gestational age and years of education were 28.3 ± 5.8 year (range: 16-47), 24.3 ± 8.9 weeks (range: 4-40), and 13.6 ± 3.6 year (range: 2-25), respectively.All women were married.Of the 484 women, 234 (48.3%) were nulliparous, 22.9% were employed, 41.1% had a university degree, and 85.4% were in a middle or high-income category.Among women who were employed, 54 women had been working at home since the COVID-19 outbreak.Thirty-eight women reported that they had an infected person among their relatives and 20 reported at least one death due to COVID-19 in their extended families.These two groups had a higher level of fear of COVID-19 than their counterparts (p = 0.01 and p = 0.002, respectively).There was no signi cant difference in fear of COVID-19 between nulliparas and primi/multiparas (p = 0.313).Women in their second and third trimester of pregnancy had a higher level of fear of COVID-19 than those in their rst trimester.The mean scores of the WHO-5 well-being index and the CWS were (64.9 ± 29.0) and (38.5 ± 22.7), respectively.Of the 484 women, 111 (24.4%) had a low level of well-being requiring further evaluation.
Table 1 shows women's worry by their socio-demographic/obstetric characteristics.Women with one of the following attributes had a higher level of worry in comparison with their counterparts: age < 30 years, nulliparous, employed, those with a low family income, those with higher education levels, those who were in the second and third trimester of pregnancy, those with a high level of fear of COVID-19, and those who had at least one COVID-19 infected person in their relatives.Women who had a close family member with chronic disease had a lower level of worry than their counterparts (p = 0.034).Further investigation revealed that the mean score of socio-medical worries was lower in women who had a close family member with chronic disease than their counterparts (p = 0.008).Women who participated in the study during the rst wave of the COVID-19 had a higher level of worry than those who registered during the second wave of the disease in Iran (p < 0.001) (Table 1).
The results of multiple logistic regression analysis on worry scores indicates that the predictors of a low level of women's worry are the increased level of fear of COVID-19, a low family income, employment status, nulliparity, and having no close family member with chronic disease (Table 2).  3 shows women's well-being by their socio-demographic/obstetric characteristics.Women with one of the following attributes had a lower level of well-being in comparison with their counterparts: women with at least one COVID-infected person among relatives, those with at least one death among their relatives due to COVID-19, and women with a high level of fear of COVID-19.Table 4 indicates that there are statistically signi cant differences in the mean scores of the Cambridge worry factors for subgroups of women classi ed according to their WHO-5 well-being score.The results of the logistic regression analysis on well-being scores showed that there is a signi cant association between the level of well-being in pregnant women with worry about fetus health (OR = 1.081, p = 0.005), worry about their own health and relationships (OR = 1.055, p = .047),and having at least one infected person with COVID-19 among relatives (OR = 2.095, p = 0.039) (Table 5).We compared pregnant women's worries during the COVID-19 pandemic and their worries according to our study conducted in 2016 [13].The results indicate that the mean scores for the two factors designated as 'worry about the fetus health' and 'socio-economic' are statistically different between the two studies (p < 0.05).Fetus health mean score in the current study was lower than that of the previous study (p = 0.024).Socio-economic mean score in the current study was higher than that of the previous study (p = 0.025) (Table 6).We compared pregnant women's wellbeing scores during the COVID-19 pandemic according to the present study with those reported in another study which was conducted in 2019 [20].The result indicates that the percentage of participants with a low level of well-being did not differ by the two periods under study (chi-square = 0.099, p = 0.753) (Table 7).The Cronbach's alpha values for the WHO-5 well-being index and for the CWS in the present study are 0.911 and 0.912, respectively.Chi-square = 0,099, p = 0.753

Discussion
We investigated well-being and worry and associated factors with each one in pregnant women during the COVID-19 epidemic.In addition, we compared the results of our study with those of the previous studies conducted before the COVID-19 pandemic.Our ndings show that predictors of women's worry are the increased level of fear of COVID-19, a low family income, employment status, nulliparity, and having no close family member with chronic disease.Having a close family member with chronic disease caused women to focus less on their own socio-medical worries such as worries about "Having nobody in delivery ward", "Giving birth", "Whether midwives provide good care in labor", "Going to hospital", and "Crowded delivery ward".Lebel and colleagues reported a higher level of pregnancy-related anxiety among Nulliparous than primi/multiparas [21].
Women's concerns about their own health and concerns about relationships and the health of the growing fetus are factors that best predict a woman's level of well-being.Another one our ndings was that having a COVID-19 infected relative had a signi cant relationship with a low level of well-being.
Pregnant women are concerned about the health of the fetus in addition to their own health.Even before the COVID-19 outbreak, the possibility of giving birth to an unhealthy baby was the most prevalent causes of worry and anxiety in pregnant women [13,22].
We found that women's well-being as indicated by the WHO-5 overall scores, did not change from our previous study to the present study.This result is not in agreement with a previous Canadian study carried on 1987 pregnant women conducted on 5-20 March 2020.The Canadian study found an elevated rate of depression and anxiety symptoms among pregnant women in comparison with previous meta analyses [21].In another study of 5866 pregnant and breastfeeding women during the lockdown period in Belgium, an elevated rate of depression and anxiety symptoms was reported in comparison with reported rates prior to the pandemic [23].In fact, most studies were conducted in the COVID-19 epidemic early on or in the quarantine period when psychological well-being of pregnant women had been severely affected.We conducted this study in the period after the rst wave of the epidemic in Iran when the quarantine period had ended and COVID-19 infection rates and death toll had decreased.These favorable developments might have been interpreted by women as a sign that the pandemic was coming to an end.
That may have affected positively pregnant women's feelings and functioning.Furthermore, the percentage of women experiencing a low well-being state was relatively high in comparison with previous studies.These percentages were 9.18% in Mumbai [24] and 19.6% in Osasco, São Paulo [25].
Our results indicate that the level of worry among pregnant women had decreased during the second wave of COVID-19 epidemic compared to its level during the rst wave.Our study showed that in comparison with our previous study before the pandemic, women's concerns about fetus health had decreased but women's worries about socio economic matters had increased [13].The availability of ultrasound scans during recent years may have had a role in decreasing the women's worries about fetus health.The results of a study on postpartum women indicates that on average women receive 5.9 ultrasound scans during pregnancy.Obtaining assurance about fetus health was the rst reason given by women for undergoing ultrasound scans [26].In addition, in 2014, the health transformation plan (HTP) was launched in the Iranian health system.One of the HTP packages had been designed with speci c purpose of improving maternal health [27].The package included several interventions such as holding free childbirth preparatory classes in both hospitals and health centers and providing the option of having a midwife at birth for pregnant women.Women participating in this study had already taken part in the virtual childbirth preparatory classes.They also had the option of having a midwife at labor.It is possible that these interventions had reduced concerns about fetus health among pregnant women.COVID-19 pandemic has negatively affected the economy almost in all countries [28] leading to increased poverty rate [29].Therefore, it is not surprising to nd that women were experiencing higher levels of worry about household livelihood and expenses.
The rst limitation of our study was that because it was an online survey, women who did not have a smartphone were not able to participate in it.Those women may have different levels of fear, worry, and well-being.Although the two studies, whose results were compared with the present study, were conducted on the same population and in the same community, the samples are not necessarily similar.
The sample in the present study consists of women with higher education levels than the study conducted in 2019 [20].
Online surveys have their own strengths and weaknesses.They save time for both participants and investigators.It is possible to design the questionnaire in such a way that participants do not miss any questions or items.Another strength point of this study is that we could perform comparisons between this study, which was conducted during the COVID-19 period and two previous studies which were published in 2019 and 2016.The third strong point of the study is that we used the same scales to measure well-being and worry in all the three studies mentioned above.This enabled us to compare worry and well-being between the studies.This post-quarantine study provided us with an opportunity to examine the impact of this prolonged epidemic on women's well-being and worry.

Conclusions
In this study, we investigated worry and well-being in pregnant women during the COVID-19 pandemic.We also examined whether their worry and the levels of wellbeing had changed when compared with the results of our previous studies before the pandemic.To summarize, our ndings call attention to the problems of pregnant women who have one or more of the following characteristics: nulliparous, being in paid employment, low-income, and being severely fearful of COVID-19.We recommend setting up support groups for these women to help them overcome their worries during the pandemic.
Our results indicate a close relationship between worry and well-being in pregnant women.More precisely, pregnant women's worries about the health of their fetus, their own health and about their relationships with their husbands and family members had negative impact on their well-being.These ndings call for actions by health care providers and in particular midwives with the aim of supporting pregnant women.
In the current circumstances, this can be achieved best by setting up online groups to attend to their concerns and refer those with high levels of worry to counselors.
We also found that pregnant women's concerns about fetus health decreased and their socio economic concerns increased in comparison with the results of our previous study conducted in 2016.It seems that measures introduced in 2016 with the aim of reducing women's worry about childbirth, have been effective and therefore should be continued.To decrease women's socio economic concerns, Zero indicates experiencing good feelings at no time and ve indicates experiencing good feelings all the time.The minimum and maximum score of the scale are 0 and 25 respectively.The total score are usually transformed to a scale of 0 to 100.The cut-off point of 50 was considered for screening for depression.Individuals with scores less than fty are referred for further evaluations.The World Health organization translated the scale into several languages including Persian[19].Mortazavi and Colleagues investigated the validity and reliability of the Persian version in pregnant women and the results indicates that the scale is unidimentionl with excellent reliability (Cronbach's alpha = 0.85)[18].

Table 1
Women's worry by their socio-demographic/obstetric characteristics.

Table 2
Predictors of worry among studied variables (results of multiple regression analysis on worry scores).

Table 3
Women's well-being by their socio-demographic characteristics.

Table 4
Differences in the sub-groups of worry by level of psychological well-being.p<0.05, **p<0.01,Variables entered the logistic regression analysis as independent variable include infection with COVID−19 in relatives, Death due to COVID−19 in relatives, Fear of COVID, four factors of the worry scale.Method of analysis: Backward LR b Logistic regression: p < 0.05.cLogistic regression: p = 0.055.*

Table 6
Comparison of pregnant women's worries during the COVID-19 pandemic and the previous study conducted on 2016.

Table 7
Comparison of pregnant women's well-being during the COVID-19 pandemic and the study conducted on 2019.