Risk and Protective Factors Associated with Depression and Anxiety among Pregnant Women during the COVID-19 Pandemic ()
1. Introduction
The COVID-19 pandemic may have impacted society, particularly the mental health of perinatal women. In Japan, the first case of infection was confirmed and announced in January 2020. A state of emergency was declared in Osaka four times between 2020 and 2021, making it advisable to stay outside the city. The World Health Organization (WHO) had recommended pregnant women to take precautions to protect themselves against COVID-19 as changes in the body and immune system may increase their susceptibility to the serious consequences of some respiratory infections [1] . Therefore, pregnant women were expected to be concerned about COVID-19 and engage in precautionary behaviours to avoid it.
A study of 105 pregnant and 105 non-pregnant women surveyed four times during the COVID-19 pandemic for anxiety and depression reported that pregnant women had a more pronounced increase and a weaker decrease in initial symptoms than non-pregnant women [2] . Pregnant women may have become more depressed and anxious because of the fear of COVID-19. The rate of depression among pregnant women during the COVID-19 pandemic was reportedly 25% - 30% [3] [4] [5] [6] . The rate of depression among pregnant women before the COVID-19 pandemic was 16.4% [7] , which is likely to have increased after the pandemic.
The risk factors associated with depression among pregnant women during COVID-19 were “distress from COVID-19-related experiences”, “reduced/low income”, “unemployment”, “anxiety”, “history of mental illness”, “lack of social support”, and “reduced/lack of exercise”. However, protective factors associated with pregnant Japanese women were not reported [8] . Studies of pregnant women during the COVID-19 pandemic predicted the potential association of prenatal depression and anxiety with postpartum depression [9] . Therefore, there is a need to identify protective factors associated with depression and anxiety among pregnant women in Japan. This study investigated the risk and protective factors associated with depression and anxiety among pregnant Japanese women during the COVID-19 pandemic.
2. Methods
2.1. Study Design and Participants
This cross-sectional online survey was conducted using Survey Monkey’s online system. This system is ISO 27001 certified as an international standard for information security. Data were collected between October 2022 and May 2023, i.e. from the “8th wave” of the COVID-19 pandemic to just before it was labelled as a “Class 5 Infectious Disease”.
Pregnant women were recruited from two general hospitals in Osaka, Japan. Inclusion criteria were: pregnant women aged ≥ 18 years, those with ≥22 weeks’ gestation beyond the time of the miscarriage, and those who attended antenatal health examinations at obstetrics. Pregnant women whose native language was not Japanese were excluded. Pregnant women who met the inclusion criteria were informed of the survey while they waited for their prenatal health examinations in an outpatient obstetric clinic. Pregnant women who consented to participate in the study were asked to complete an online questionnaire.
The sample size was 134 participants, which was calculated using the power analysis software G * Power with a significance level of 0.05, power of 0.8, and effect size of 0.5.
2.2. Measures
2.2.1. Characteristics
The participants were asked to provide information regarding their gestational age, delivery history, marital status, financial concerns, infertility treatment, pregnancy complications, history of mental illness, changes in work patterns due to the COVID-19 pandemic, partner telecommuting due to the COVID-19 pandemic, postpartum support, and decreased support due to the COVID-19 pandemic.
2.2.2. Behaviour
Participants were asked if they attempted to behave according to the following 18 items. They were asked to answer using four options: not at all, rarely, sometimes, and always.
The 18 items were regular life, getting enough sleep, early to bed and early to rise, exposure to sunlight, three meals a day, nutritional balance, frequent hand washing, alcohol disinfection, frequent ventilation, getting information about COVID-19, going out to avoid crowds, communication with partner, communication with family members, exercise, exercise at home, exercise outside the home, hobbies and mood swings, and getting support.
2.2.3. Depression
The Japanese version of the Patient Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms. The PHQ-9 was developed by Kroenke et al. [10] and translated into Japanese by Muramatsu et al. [11] . This scale has 10 questions scored from 0 to 3 points, with total scores ranging from 0 to 27. Scores of 0 - 4, 5 - 9, 10 - 14, 15 - 19, and 20 - 27 represent minimal, mild, moderate, moderately severe, and severe depression, respectively [12] . The sensitivity and specificity of the Japanese version of the PHQ-9 are 90.5% and 76.6%, respectively [12] .
2.2.4. Anxiety
Anxiety was assessed using the Japanese version of the General Anxiety Disorder-7 (GAD-7) scale. The GAD-7 was developed by Spitzer et al. [13] and translated into Japanese by Muramatsu et al. [14] [15] . This scale has seven questions scored from 0 to 3 points, with total scores ranging from 0 to 21. Scores of 0 - 4, 5 - 10, 10 - 14, and 15 - 21 represent minimal, mild, moderate, and severe anxiety, respectively [15] . The sensitivity and specificity of this scale are 89% and 82%, respectively [13] .
2.3. Statistical Analysis
Descriptive statistics were used to describe the participants’ characteristics and behaviours. The χ2 test or Fisher’s exact test was used to examine factors associated with depression and anxiety during pregnancy. In addition, a multiple logistic regression analysis using the method of increasing variables (likelihood ratio) was conducted, with the presence or absence of depressive and anxiety symptoms among pregnant women as the dependent variable and participants’ characteristics and behaviours as independent variables.
All statistical analyses were performed using the SPSS Statistics software (version 27.0; International Business Machines Corporation, NY, USA). The statistical significance level was set at 5%.
2.4. Ethical Considerations
This study was approved by the Ethics Committees of University A (approval number: 2022-076), Hospital B (2022-1), and Hospital C (5648). All participants were informed about the study. Consent was obtained by submitting the online questionnaire and responding to the check-in consent box.
3. Results
Of the 312 pregnant women approached, 159 (51.0%) agreed to participate in our study. The analysis included 157 (50.3%) participants, excluding two who reported < 22 weeks of gestation.
3.1. Characteristics of Participants
The participant characteristics are presented in Table 1.
In this study, the mean age of the 157 pregnant women was 32.18 ± 5.31 years; 94 were primiparas (59.9%), 147 (93.6%) were married, 77 (49.0%) reported financial concerns, and 22 (14.0%) had a history of mental illness.
3.2. Depression and Anxiety
Of the 157 participants, 74 (47.1%) with scores of ≥5 reported more than mild depressive symptoms on the PHQ-9 and 56 (35.7%) with scores of ≥5 reported more than mild anxiety symptoms on the GAD-7 (Table 2). In this study, 47.1% of the participants scored ≥ 5 while 14.6% of the participants scored ≥ 10 on the PHQ-9 scale. Furthermore, 35.7% of the participants in this study scored ≥ 5 on the GAD-7 scale.
3.3. Behaviour
The behavioural methods used by the participants are summarised in Table 3. In this study, 90 women (57.3%) were engaged in some form of “exercise”, 55 (35.0%) were engaged in “exercise at home”, and 78 (49.7%) were engaged in
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Table 1. Participant characteristics (n = 157).
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Table 2. Severity of depression (PHQ-9) and anxiety symptoms (GAD-7) (n = 157).
Note: Abbreviations: PHQ-9 = Patient Health Questionnaire-9, GAD-7 = General Anxiety Disorder-7.
“exercise outside the home”. In addition, 147 women (93.6%) were engaged in “letting the sun in”, and 134 women (85.4%) were engaged in “hobbies or mood swings”.
3.4. Participants’ Characteristics Associated with Depression and Anxiety
Table 4 lists the results of the χ2 test or Fisher’s exact test for participant characteristics associated with depression and anxiety symptoms. “History of mental
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Table 3. Participant behaviours (n = 157).
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Table 4. Participant characteristics associated with depression and anxiety symptoms.
Note. a: χ2 test, b: Fisher’s exact test, *p < .05.
illness” was found to be a significant characteristic among participants for both depression (p = .033) and anxiety (p = .013). Anxiety was found to be significant for those who were “unmarried” (p = .035).
3.5. Behaviours Associated with Depression and Anxiety Symptoms
Table 5 lists the results of the χ2 test or Fisher’s exact test for the behaviours associated with depression and anxiety symptoms among pregnant women. “Exposure to sunlight” (p = .047), “exercise” (p = .006), “exercise at home” (p = .020), “exercise outside the home” (p = .002), and “hobbies and mood swings” (p = .020) were found to be significantly associated with depression symptoms
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Table 5. The behaviors associated with depression and anxiety symptoms among pregnant women.
Note. a: χ2 test, b: Fisher 's exact test, * p < .05, ** p < .01.
among pregnant women, while “exercise at home” (p = .003) and “hobbies and mood swings” (p = .006) were significantly associated with anxiety symptoms.
The results of the multivariate logistic regression analysis are presented in Table 6. Factors associated with depression included a “history of mental illness” and “exercise outside the home”. “History of mental illness” was a risk factor (odds ratio [OR]: 3.279, 95% confidence interval [CI] for OR: 1.202 - 8.946), while “exercise outside the home” was a protective factor against depression among pregnant women during the COVID-19 pandemic. The odds ratio of having depressive symptoms was 0.332 (95% CI: .168 -.652) for pregnant women who were committed to “exercise outside the home”. Factors associated with anxiety were being “unmarried”, having a “history of mental illness”, and engaging in “exercise at home”. Being “unmarried” (OR: 6.146, 95% CI: 1.418 - 26.637) and having a “history of mental illness” (OR: 3.981, 95% CI: 1.489 - 10.644) were risk factors, while “exercise at home” was a protective factor for
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Table 6. Results of multivariate logistic regression analysis of the factors associated with depression and anxiety symptoms.
Note: OR and 95% Confidence Interval for OR derived from a multivariate logistic regression model. Abbreviations: B = unstandardized coefficient, SE = standard error of the mean, Wald = Wald test, df = degree of freedom.
anxiety in pregnant women during the COVID-19 pandemic. The odds ratio of having anxiety symptoms was .292 (95% CI: .129 - .661) for pregnant women who were committed to “exercise at home”.
4. Discussion
In the present study, 47.1% of the participants scored ≥ 5 while 14.6% of the participants scored ≥ 10 on the PHQ-9 scale. Previous studies have reported that 25.8 to 48.7% pregnant women scored PHQ-9 scores ≥ 5, while 5.3% to 59.2% scored PHQ-9 scores ≥ 10 during the COVID-19 pandemic [16] - [26] . Furthermore, 35.7% of the participants in the present study scored ≥ 5 on the GAD-7 scale. In a systematic review of the effects of the COVID-19 pandemic, the rate of anxiety symptoms among pregnant women was 34% - 40% [4] [27] . Thus, the depression and anxiety levels of the participants in the present study did not differ from those reported in previous studies.
In this study, “exercise outside the home” was found to be a protective factor against depression among pregnant women during the COVID-19 pandemic. A lack of or decreased exercise has been reported as a risk factor for depression [18] [22] [28] [29] , but not a protective factor against depression among pregnant women during the COVID-19 pandemic. Therefore, this result is significant. Light exercise outside the home, such as walking, may have had a protective effect against depression among pregnant women during the COVID-19 pandemic. Recommending exercise to pregnant women without exercise restrictions may help prevent depression.
Exercise at home was a protective factor against anxiety among pregnant women during the COVID-19 pandemic. For pregnant women with concerns regarding infection during outdoor activities during the COVID-19 pandemic, exercising inside their homes may have been reassuring. Lebel et al. reported that anxiety symptoms among pregnant women during the COVID-19 pandemic decreased when they engaged in extensive physical activity [30] . However, pregnant women who can exercise may include those without physical complications or abnormalities during pregnancy. Therefore, this result should be interpreted with caution.
In addition, 71.6% of pregnant women reported not exercising in the post-pandemic era [22] and 61.8% of pregnant women reduced their physical activity during the lockdown [31] . In this study, 42.7% of pregnant women did not engage in exercise, and 50.3% did not engage in outdoor exercise; these percentages were smaller than those in previous studies. This might be because the present study was conducted in the “8th wave” of the COVID-19 pandemic, just before the disease became a category 5 infectious disease and the threat of infection eased. In addition, 30.6% of pregnant women continued to exercise at home compared with 8% of non-pregnant women in the early stages of the COVID-19 pandemic [32] . In the present study, 35.0% of the participants exercised at home, a percentage similar to that reported in a previous study. This is likely because pregnant women behave independently of the idea of having a healthy life with their foetuses.
A history of mental illness was a risk factor for depression and anxiety among pregnant women during the COVID-19 pandemic. It has also been reported as a risk factor for depression among pregnant women during [33] [34] [35] [36] [37] and before the pandemic [38] in previous studies. In addition, being “unmarried” was a risk factor for anxiety among pregnant women during the COVID-19 pandemic. Pregnant women with a single/divorced/widowed marital status were reported to have a higher risk of anxiety than married pregnant women during the COVID-19 pandemic in a previous study [22] . Although the odds ratio in this study was higher than in previous studies, unmarried pregnant women had a higher risk of anxiety than married pregnant women, and the presence of a husband was thought to alleviate pregnant women’s anxiety.
Thus, our study revealed risk and protective factors associated with depression and anxiety among pregnant women during the COVID-19 pandemic. These results may be useful in providing psychological support to pregnant women following the COVID-19 outbreak.
5. Limitations
This study has two limitations. First, we did not examine the relationship between pregnant women’s behaviours and exercise limitations. Second, we did not examine the exercise content of pregnant women, such as exercise type, intensity, frequency, or duration. Therefore, future studies can explore the potential individual differences in their perception of exercise.
6. Conclusion
In the present study, a history of mental illness was found to be a risk factor for depression and anxiety among pregnant women during the COVID-19 pandemic, whereas unmarried status was a risk factor for anxiety. In contrast, outdoor and indoor exercises were protective factors against depression and anxiety, respectively. Therefore, exercise may have protected pregnant women from depression and anxiety during the COVID-19 pandemic. Encouraging exercise may help maintain the mental health of pregnant women who do not have exercise restrictions.
Acknowledgements
We are grateful to the participants and hospital staff for their cooperation.
Funding
This work was supported by the JSPS KAKENHI Grant-in-Aid for Research Activity (start-up number: JP22K21187).
Complement
This study will be partially published by the 19th Japan Society of Perinatal Mental Health in 2023.