Psychobehavioral Responses, Post‐Traumatic Stress and Depression in Pregnancy During the Early Phase of COVID‐19 Outbreak

Table 1 shows sample characteristics and relevant variables included in the study. Among a total of 1908 questionnaires returned, 1901 women provided valid data (mean [SD] age, 28.9 [4.7] years). All were married or cohabiting except 14 respondents. More than half of the sample population were educated to at least post‐secondary levels. Nearly half reported themselves as full‐ or part‐time employed, or housewife. Nearly half of women were primiparas. Our sample included pregnant women from all regions in China, and 5% of the respondents were from Hubei province in which the epicenter Wuhan is located, which is similar to the proportion of the whole Hubei population in China (4%, χ²=0.11, df=1, p=0.739). There were 11% of participants with gestational complications, and 8% of them suffering with depression of any forms in the past.

Prevalence of probable PND (EPDS score ≥13) in the sample was 34% whilst more than half (58%) of the women reported depressive symptoms (EPDS score ≥10; Table 1). In respect of specific symptoms (identified by each EPDS item), more than half of the women reported frequent depressive symptoms in terms of self‐blaming, anxiety/worry, panic/scare, and feeling burdened (see items 3–6 in Table 2). The prevalence of suspected PTSD (PCL‐S score ≥14) among pregnant women was 40%. Women with suspected PTSD had 683% higher risk of probable PND compared to those non‐suspected (OR=7.83, 95% CI, 6.29, 9.75, p<0.001; Table S1).

Figure 1 outlines the prevalence of probable PND (above) and suspected PTSD (below) across regions in China. The prevalence of probable PND ranged from 25% to 44% whilst the prevalence of suspected PTSD ranged from 35% to 48%. Comparing the prevalence of suspected PTSD between Hubei province in which the epicenter of Wuhan (COVID‐19) is located and non‐Hubei provinces, Hubei province had a higher prevalence than other provinces (49% vs. 39%, p=0.044).

Figure 2 depicts the distribution of psychological and behavioral responses among the pregnant women. Details of the statistics are available in Table S2. There were almost half of pregnant women expressing higher levels of anxiousness (“very worried”) about their incoming new‐borns contracting COVID‐19; higher levels of anxiousness expressed regarding their spouse/partner and other relatives also accounted for nearly half of the sample (see Panel A). In contrast, anxiousness about themselves and friends at higher levels tended to constitute a relatively lower proportion but still reached 30% and 24%, respectively. In addition to medium and lower levels, anxiousness about COVID‐19 infection were reported in the majority of the pregnant women ranging from 91% to 96%. This shows that only a minority of them (4%–9%) expressed completely no anxiety about infection of themselves or members within their social network. In respect of specific psychological responses (Panel B), including anxiety even during staying at home, lack of security, and loss of freedom, approximately 65% of respondents admitted undergoing these negative experiences due to the course of infectious outbreak (reporting “strongly agree” or “agree”). Stemming from the onset of this outbreak, increased frequency of particular prevention behaviors was reported by our respondents (Panels C1‐C3). To reduce risk of infection, more frequent handwashing comprised over 81% of the sample while less than 18% reported no change. Facemask use also became prevalent among pregnant women of which 78% wore facemasks all the time or most of the time. Nonetheless, there was a small proportion of women who reported never or rarely wearing facemasks. More frequent or complete housebound behaviors were also undertaken among 96% of women with more than half of them being totally housebound. By contrast, gloves wearing was less common with more than half not adopting such precautionary measure while only fewer than a quarter of women reporting wearing gloves all the time, most of time or sometimes.

In terms of psycho‐behavioral responses related to pregnancy (Panels D1–D3, Figure 2), more than three quarters of women conjured up a feeling of anxiousness or extreme anxiousness related to miscarriage and/or premature birth if they were infected. Despite the ongoing COVID‐19 epidemic, nearly half of pregnant women indicated no feeling of fear for antenatal consultation undertaken in hospital. However, nearly two thirds of them in fact voiced in fear of antenatal check‐up in hospital. Regarding antenatal appointments, half of them preferred the postponement of their visit while approximately one‐fifth women opted for cancellation.

Our study found high prevalences of probable PND (34%) and suspected PTSD (40%) among pregnant women during the early stage of COVID‐19 outbreak (from January to early February 2020). The observed prevalence of these two disorders appeared to be much higher during the outbreak compared to those reported during the periods of no infectious disease outbreaks (17, 18). The prevalence of probable PND observed during the ongoing traumatic event in this study is much higher than the previously reported estimates 5%–23% (19, 20, 21). In terms of suspected PTSD, varying between degrees of exposure, the observed prevalence in this study is comparable to the upper bound of previously reported 30%–40% among direct victims and is much higher than 5%–10% in the general population (18, 22). Our results also echo the recent findings (23, 24) that the prevalence of mental disorders in emergency settings have been higher in past decades, indicating the potential of substantial population underdiagnosed and undertreated.

Women with probable PND assessed using the screening instrument EPDS in this study characterize the population who were experiencing depressive symptomatology during the unprecedented scale of disease outbreak taking place in China, which is deemed to be more extensively influential than the severe acute respiratory syndrome outbreak in 2003 (25). Probable PND cases identified by the EPDS (score≥13) require emergency interventions according to the recommendations specified in existing guidelines (26, 27). Depression during pregnancy was identified to be one of the strongest predictors for later suffering with PPD, accounting for moderate effect size (approximately 0.45), as shown in earlier studies (3, 28). Our findings signify a pressing need that depressive symptoms occurring during prenatal period should be recognized and those at high risk should be closely evaluated or referred if needed. This is because severe conditions that are not treated will pose long lasting adversities to the health of the mothers and their children. This could also extend to the whole family and which increase the burden on the existing healthcare system (29). Also, same for other chronic mental health disorders, early detection can result in reduced sequalae and better quality of life (23). Being aware and open to tackling perinatal depression should be viewed as a high priority given the current emergency in China.

Although throughout the article we primarily referred to probable PND, those population at less severe levels but demonstrating depressive symptoms to certain extent or considered as mild PND, that is, EPDS score≥10 but lower than 13, should not be neglected (13, 30). As mentioned above, depression during pregnancy, especially the untreated forms, can contribute to subsequent presence of PPD. Therefore, during the prenatal period, assessment and reassessment in 2–4 weeks for women at this milder symptomatology level should be followed up to determine whether further healthcare support or treatment is required. Given the unfolding of PND being somewhat unpredictable, for example, mild symptoms at early stage but can persist or develop (30), monitoring practice as well as women being aware of their mental health should be considered. This may help mitigate the situation where women do not recognize their depressive symptoms until after childbirth or feel embarrassed to seek help due to stigma (13, 31).

High prevalence of suspected PTSD in our study represents the real‐time percentage of the Chinese pregnant population who are mentally affected by the current and ongoing pneumonia‐like disease. Given that such prevailing concerns on mental health problems may indicate crisis or unresolved trauma (32), high percentage of positive scores on the PTSD checklist may speak up for the possibility of this psychopathology. High proportion of suspected PTSD cases identified in our study reflect the circumstance that mental health concerns become more prominent following the emergent outbreak itself. Large proportion of our sample who voiced their anxiety from aspects of psychological and behavioral responses also point up the nexus between traumatic stress and mental health problems. Special attention to outbreak‐related distress among pregnant women is urgently needed, which is in line with a recent call for mental health campaign (7).

Given that the outbreak is ongoing, high prevalence of PTSD suspected cases could be potentially overestimated. Irrespective of such potential upward bias, its association with high PND prevalence observed in this study should not be deemed as unworthy of attention. In fact, history‐of‐depression‐adjusted odds ratio of probable PND is estimated to be 683% higher in those PTSD‐suspected cases compared to non‐suspected cases (Table S1). This suggests the COVID‐induced stress could exert long‐term influence on postnatal affect. Apart from such psychopathological mechanism, it is also likely that unprecedented control measures, for example, city lockdown or community quarantines, have intensified such outbreak‐induced stress and, in turn, pose greater emotional impacts on pregnant women (33). Given the measures being underway at the time of data collection, it is anticipated that the reported prevalence will prevail for an indefinite period depending on the progress of outbreak development and the effectiveness of recent and upcoming new measures. Such compelling results in this study articulate the potential devasting effects of acute diseases on pregnant women’s mental health, urging healthcare to be prioritized in such ever under‐resourced area of public health (34). Besides, it is possible that part of the observed association between PND and PTSD can be explained by the highly correlated symptoms reported by those experiencing both conditions (32, 35).

Notwithstanding the outbreak firstly taking place in China, sharply increasing cases (1) reported in neighboring Asian countries as well as countries across wider regions imply that the identified traumatic stress‐linked mental health issues among pregnant women could be of upcoming worldwide concerns, following the circumstance that the COVID‐19 itself is now pandemic and has been announced as an international emergency by the WHO (36).

There are several strengths and limitations in this study. Our study relied on the analyses of a national‐wide sample of pregnant women from all regions in China. We characterized the presence of psychological and behavioral responses towards the onset of outbreak and examined the associations between demographics, suspected PTSD, and risk of PND. Universal results across multiple variables between Hubei and non‐Hubei subsamples (see Table S3) suggest mental health problems can be manifest and generalizable in a range of areas within the nation. Measurement of depression during pregnancy and risk of PTSD were based on the commonly used screening instruments (12, 16). Diagnoses of specific diseases should always be carefully evaluated following structured clinical interviews administered by healthcare professionals. Due to the nature of design, we may not be able to infer the causality between outbreak impact and mental health outcomes. Limited available data at this stage may have confined our abilities in more descriptive and general analyses. Intricate and underlying relationships among variables of interest should be further elucidated when complex data become available. One of possible directions can be the influence of social media. Digital health may also contribute to our understanding (37).

In conclusion, high prevalence of probable PND observed in our study suggests the transcending impact of COVID‐19 on mental health via potential traumatic stress. This calls for raised awareness of mental health issues in society and healthcare to be prioritized in this under‐resourced area. Special attention and support for the vulnerable subgroup population are highly needed. Contingent on the progression of such pandemic and the effectiveness of implemented measures, mental health care should become part of public health measures during the present outbreak and should continue to be intensified to empower the health system for post‐outbreak periods.