The Impact of the COVID-19 Pandemic on Pregnant Women with Perinatal Anxiety Symptoms in Pakistan: A Qualitative Study

Nida Rauf, Shaffaq Zulfiqar, Sidra Mumtaz, Hadia Maryam, Rabail Shoukat, Abid Malik, Armaan A Rowther, Atif Rahman, Pamela J Surkan, Najia Atif, Nida Rauf, Shaffaq Zulfiqar, Sidra Mumtaz, Hadia Maryam, Rabail Shoukat, Abid Malik, Armaan A Rowther, Atif Rahman, Pamela J Surkan, Najia Atif

Abstract

The impact of coronavirus disease 2019 (COVID-19) on people with existing mental health conditions is likely to be high. We explored the consequences of the pandemic on women of lower socioeconomic status with prenatal anxiety symptoms living in urban Rawalpindi, Pakistan. This qualitative study was embedded within an ongoing randomized controlled trial of psychosocial intervention for prenatal anxiety at a public hospital in Rawalpindi. The participants were women with symptoms of anxiety who had received or were receiving the intervention. In total, 27 interviews were conducted; 13 women were in their third trimester of pregnancy, and 14 were in their postnatal period. The data were collected through in-depth interviews and analyzed using framework analysis. Key findings were that during the pandemic, women experienced increased perinatal anxiety that was linked to greater financial problems, uncertainties over availability of appropriate obstetric healthcare, and a lack of trust in health professionals. Women experienced increased levels of fear for their own and their baby's health and safety, especially due to fear of infection. COVID-19 appears to have contributed to symptoms of anxiety in women already predisposed to anxiety in the prenatal period. Efforts to address women's heightened anxiety due to the pandemic are likely to have public health benefits.

Keywords: COVID-19; anxiety symptoms; low- and middle-income countries; mental health; pregnant women.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Figures

Figure 1
Figure 1
Emergent themes, subthemes, and codes from thematic analysis.

References

    1. Sharma J.B., Sharma E. Obstetrics and COVID-19. J. Pak. Med. Assoc. 2020;70(Suppl. S3):S104–S107. doi: 10.5455/JPMA.24.
    1. Yue C., Liu C., Wang J., Zhang M., Wu H., Li C., Yang X. Association between social support and anxiety among pregnant women in the third trimester during the coronavirus disease 2019 (COVID-19) epidemic in Qingdao, China: The mediating effect of risk perception. Int. J. Soc. Psychiatry. 2021;67:120–127. doi: 10.1177/0020764020941567.
    1. Bao Y., Sun Y., Meng S., Shi J., Lu L. 2019-nCoV epidemic: Address mental health care to empower society. Lancet. 2020;395:e37–e38. doi: 10.1016/S0140-6736(20)30309-3.
    1. Duan L., Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry. 2020;7:300–302. doi: 10.1016/S2215-0366(20)30073-0.
    1. Xiong J., Lipsitz O., Nasri F., Lui L.M.W., Gill H., Phan L., Chen-Li D., Iacobucci M., Ho R., Majeed A., et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J. Affect. Disord. 2020;277:55–64. doi: 10.1016/j.jad.2020.08.001.
    1. Goldmann E., Galea S. Mental health consequences of disasters. Annu. Rev. Public Health. 2014;35:169–183. doi: 10.1146/annurev-publhealth-032013-182435.
    1. Hao F., Tan W., Jiang L., Zhang L., Zhao X., Zou Y., Hu Y., Luo X., Jiang X., McIntyre R.S., et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav. Immun. 2020;87:100–106. doi: 10.1016/j.bbi.2020.04.069.
    1. Shah P.S., Diambomba Y., Acharya G., Morris S.K., Bitnun A. Classification system and case definition for SARS-CoV-2 infection in pregnant women, fetuses, and neonates. Acta Obstet. Gynecol. Scand. 2020;99:565–568. doi: 10.1111/aogs.13870.
    1. Moyer C.A., Compton S.D., Kaselitz E., Muzik M. Pregnancy-related anxiety during COVID-19: A nationwide survey of 2740 pregnant women. Arch. Womens Ment. Health. 2020;23:757–765. doi: 10.1007/s00737-020-01073-5.
    1. Berthelot N., Lemieux R., Garon-Bissonnette J., Drouin-Maziade C., Martel É., Maziade M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet. Gynecol. Scand. 2020;99:848–855. doi: 10.1111/aogs.13925.
    1. Lebel C., MacKinnon A., Bagshawe M., Tomfohr-Madsen L., Giesbrecht G. Corrigendum to elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic journal of affective disorders 277 (2020) 5-13. J. Affect. Disord. 2021;279:377379. doi: 10.1016/j.jad.2020.10.012.
    1. Effati-Daryani F., Zarei S., Mohammadi A., Hemmati E., Ghasemi Yngyknd S., Mirghafourvand M. Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC Psychol. 2020;8:99. doi: 10.1186/s40359-020-00464-8.
    1. Durankuş F., Aksu E. Effects of the COVID-19 pandemic on anxiety and depressive symptoms in pregnant women: A preliminary study. J. Matern. Fetal Neonatal. Med. 2020;18:1–7. doi: 10.1080/14767058.2020.1763946.
    1. Grigoriadis S., Graves L., Peer M., Mamisashvili L., Tomlinson G., Vigod S.N., Dennis C.L., Steiner M., Brown C., Cheung A., et al. Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: Systematic review and meta-analysis. J. Clin. Psychiatry. 2018;79:17r12011. doi: 10.4088/JCP.17r12011.
    1. Kotlar B., Gerson E., Petrillo S., Langer A., Tiemeier H. The impact of the COVID-19 pandemic on maternal and perinatal health: A scoping review. Reprod. Health. 2021;18:1–39. doi: 10.1186/s12978-021-01070-6.
    1. Liu X., Chen M., Wang Y., Sun L., Zhang J., Shi Y., Wang J., Zhang H., Sun G., Baker P.N., et al. Prenatal anxiety and obstetric decisions among pregnant women in Wuhan and Chongqing during the COVID-19 outbreak: A cross-sectional study. BJOG Int. J. Obstet. Gynaecol. 2020;127:1229–1240. doi: 10.1111/1471-0528.16381.
    1. Nisar M.I., Ansari N., Khalid F., Amin M., Shahbaz H., Hotwani A., Rehman N., Pugh S., Mehmood U., Rizvi A., et al. Serial population-based sero-surveys for COVID-19 in two neighborhoods of Karachi, Pakistan. Int. J. Infect. Dis. 2021;106:176–182. doi: 10.1016/j.ijid.2021.03.040.
    1. Khan H., Kalia S., Itrat A., Khan A., Kamal M., Khan M.A., Khalid R., Khalid S., Javed S., Javed S., et al. Prevalence and demographics of anxiety disorders: A snapshot from a community health centre in Pakistan. Ann. Gen. Psychiatry. 2007;6:30. doi: 10.1186/1744-859X-6-30.
    1. Biaggi A., Conroy S., Pawlby S., Pariante C.M. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J. Affect. Disord. 2016;191:62–77. doi: 10.1016/j.jad.2015.11.014.
    1. Carbonell Á., Navarro-Pérez J.J., Mestre M.V. Challenges and barriers in mental healthcare systems and their impact on the family: A systematic integrative review. Health Soc. Care Community. 2020;28:1366–1379. doi: 10.1111/hsc.12968.
    1. Najam S., Chachar A.S., Mian A. The mhgap will it bridge the mental health Treatment gap in Pakistan? [(accessed on 28 March 2021)];Pak. J. Neurol. Sci. (PJNS) 2019 14:28–33. Available online: .
    1. Surkan P.J., Hamdani S.U., Huma Z.E., Nazir H., Atif N., Rowther A.A., Chaudhri R., Zafar S., Mullany L.C., Malik A., et al. Cognitive-behavioral therapy-based intervention to treat symptoms of anxiety in pregnancy in a prenatal clinic using non-specialist providers in Pakistan: Design of a randomised trial. BMJ Open. 2020;10:e037590. doi: 10.1136/bmjopen-2020-037590.
    1. Zigmond A.S., Snaith R.P. The hospital anxiety and depression scale. Acta. Psychiatr. Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x.
    1. First M.B., Gibbon M. The structured clinical interview for DSM-IV Axis I disorders (SCID-I) and the structured clinical interview for DSM-IV Axis II disorders (SCID-II) Compr. Handb. Psychol. Assess. 2004;2:134–143.
    1. Gorman L.L., O’Hara M.W., Figueiredo B., Hayes S., Jacquemain F., Kammerer M.H., Klier C.M., Rosi S., Seneviratne G., Sutter-Dallay A.L., et al. Adaptation of the structured clinical interview for DSM-IV disorders for assessing depression in women during pregnancy and post-partum across countries and cultures. Br. J. Psychiatry Suppl. 2004;46:s17–s23. doi: 10.1192/bjp.184.46.s17.
    1. Nicogossian A., Pober D., Roy S. Evolution of telemedicine in the space program and earth applications. Telemed. J. E Health. 2001;7:1–15. doi: 10.1089/153056201300093813.
    1. Craig J., Patterson V. Introduction to the practice of telemedicine. J. Telemed. Telecare. 2005;11:3–9. doi: 10.1177/1357633X0501100102.
    1. COVID-19: Pakistani Hospitals Suspend Outpatient Clinics. Anadolu Agency; Islamabad, Pakistan: 2020.
    1. Ward D.J., Furber C., Tierney S., Swallow V. Using Framework Analysis in nursing research: A worked example. J. Adv. Nurs. 2013;69:2423–2431. doi: 10.1111/jan.12127.
    1. Iliffe S., Wilcock J., Drennan V., Goodman C., Griffin M., Knapp M., Lowery D., Manthorpe J., Rait G., Warner J. Changing practice in dementia care in the community: Developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM) Southampton (UK): NIHR J. Libr. 2015;3:2050–4322. doi: 10.3310/pgfar03030.
    1. Ali I., Ali S. Why may COVID-19 overwhelm low-income countries like Pakistan? Disaster Med. Public Health Prep. 2020:1–5. doi: 10.1017/dmp.2020.329.
    1. Government of Pakistan Pakistan Economic Survey 2018–2019. Ministry of Finance, editor. [(accessed on 28 March 2021)];Islamabad, Pakistan. 2019 Available online: .
    1. Ali A., Ahmed M., Hassan N. Socioeconomic impact of COVID-19 pandemic: Evidence from rural mountain community in Pakistan. J. Public Aff. 2020:e2355. doi: 10.1002/pa.2355.
    1. Zamudio M. 2 Chicagoans on Struggling to Make Ends Meet During the Pandemic. NPR; Chicago, IL, USA: 2020.
    1. Guo W., Li M., Dong Y., Zhou H., Zhang Z., Tian C., Qin R., Wang H., Shen Y., Du K., et al. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab. Res. Rev. 2020;36:e3319. doi: 10.1002/dmrr.3319.
    1. Lei L., Huang X., Zhang S., Yang J., Yang L., Xu M. Comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the COVID-19 epidemic in Southwestern China. Med. Sci. Monit. 2020;26:e924609. doi: 10.12659/MSM.924609.
    1. Mazza C., Ricci E., Biondi S., Colasanti M., Ferracuti S., Napoli C. A nationwide survey of psychological distress among Italian people during the COVID-19 pandemic: Immediate psychological responses and associated factors. Int. J. Environ. Res. Public Health. 2020;17:3165. doi: 10.3390/ijerph17093165.
    1. Olagoke A.A., Olagoke O.O., Hughes A.M. Exposure to coronavirus news on mainstream media: The role of risk perceptions and depression. Br. J. Health Psychol. 2020;25:865–874. doi: 10.1111/bjhp.12427.
    1. Ahmed M.Z., Ahmed O., Aibao Z., Hanbin S., Siyu L., Ahmad A. Epidemic of COVID-19 in China and associated Psychological Problems. Asian J. Psychiatr. 2020;51:102092. doi: 10.1016/j.ajp.2020.102092.
    1. Huang Y., Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res. 2020;288:112954. doi: 10.1016/j.psychres.2020.112954.
    1. Hashim A. Pakistan hospitals struggle as coronavirus cases explode. Al Jazeera. [(accessed on 29 July 2021)];2020 Jun 12; Available online: .
    1. Salman M., Raza M.H., Mustafa Z.U., Khan T.M., Asif N., Tahir H., Shehzadi N., Hussain K. The psychological effects of COVID-19 on frontline healthcare workers and how they are coping: A web-based, cross-sectional study from Pakistan. medRxiv. :2020. doi: 10.1101/2020.06.03.20119867.
    1. Children’s lives at stake, COVID threatens to undo 30 years of ‘remarkable progress’. UN-News. [(accessed on 28 January 2021)];2020 Sep 9; Available online: .
    1. Hussein J. COVID-19: What implications for sexual and reproductive health and rights globally? Sex. Reprod. Health Matters. 2020;28:1746065. doi: 10.1080/26410397.2020.1746065.
    1. Mizrak Sahin B., Kabakci E.N. The experiences of pregnant women during the COVID-19 pandemic in Turkey: A qualitative study. Women Birth. 2021;34:162–169. doi: 10.1016/j.wombi.2020.09.022.
    1. Simó S., Zúñiga L., Izquierdo M.T., Rodrigo M.F. Effects of ultrasound on anxiety and psychosocial adaptation to pregnancy. Arch. Womens Ment. Health. 2019;22:511–518. doi: 10.1007/s00737-018-0918-y.
    1. Akowuah J.A., Agyei-Baffour P., Asibey B.O. A qualitative study on the pathways to evidence-based antenatal care in periurban ghana. Obstet. Gynecol. Int. 2018;2018:4381708. doi: 10.1155/2018/4381708.
    1. Li Z., Ge J., Yang M., Feng J., Qiao M., Jiang R., Bi J., Zhan G., Xu X., Wang L., et al. Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control. Brain Behav. Immun. 2020;88:916–919. doi: 10.1016/j.bbi.2020.03.007.
    1. Erku D.A., Belachew S.A., Abrha S., Sinnollareddy M., Thomas J., Steadman K.J., Tesfaye W.H. When fear and misinformation go viral: Pharmacists′ role in deterring medication misinformation during the ‘infodemic’ surrounding COVID-19. Res. Social Adm. Pharm. 2021;17:1954–1963. doi: 10.1016/j.sapharm.2020.04.032.
    1. Moghanibashi-Mansourieh A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J. Psychiatr. 2020;51:102076. doi: 10.1016/j.ajp.2020.102076.
    1. Kermani S. Coronavirus: Rumours, fear and rising Covid deaths in Pakistan. BBC News. Jun 5, 2020.
    1. Gallup Pakistan Coronavirus Attitude Tracker Survey report- Wave 8. [(accessed on 12 July 2021)];2020 Available online: .
    1. Rehman Z.U., Schmall E. A COVID-19 Surge and Conspiracy Theories Roil Pakistan. The New York Times; New York, NY, USA: Dec 19, 2020. [(accessed on 12 July 2021)]. Available online: .
    1. El-Saharty S., Ohno N. [(accessed on 18 April 2021)];South Asia’s Quest for Reduced Maternal Mortality: What the Data Show. 2015 Jan 13; World Bank Group. South Asia. Available online: .
    1. Atif N., Nazir H., Zafar S., Chaudhri R., Atiq M., Mullany L.C., Rowther A.A., Malik A., Surkan P.J., Rahman A. Development of a psychological intervention to address anxiety during pregnancy in a low-income country. Front. Psychiatry. 2020;10:927. doi: 10.3389/fpsyt.2019.00927.
    1. Mayer Y., Etgar S., Shiffman N., Lurie I. The fear of COVID-19 familial infection scale: Initial psychometric examination. PstArXiv. :2020. doi: 10.31234/.
    1. Fontanesi L., Marchetti D., Mazza C., Di Giandomenico S., Roma P., Verrocchio M.C. The effect of the COVID-19 lockdown on parents: A call to adopt urgent measures. Psychol. Trauma. 2020;12:S79–S81. doi: 10.1037/tra0000672.
    1. Assari S., Habibzadeh P. The COVID-19 emergency response should include a mental health component. Arch. Iran. Med. 2020;23:281–282. doi: 10.34172/aim.2020.12.
    1. Horesh D., Brown A.D. Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. Psychol. Trauma. 2020;12:331–335. doi: 10.1037/tra0000592.
    1. Galea S., Merchant R.M., Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Intern. Med. 2020;180:817–818. doi: 10.1001/jamainternmed.2020.1562.
    1. Usher K., Durkin J., Bhullar N. The COVID-19 pandemic and mental health impacts. Int. J. Ment. Health Nurs. 2020;29:315. doi: 10.1111/inm.12726.
    1. Wall V., Premji S.S., Letourneau N., McCaffrey G., Nyanza E.C. Factors associated with pregnancy-related anxiety in Tanzanian women: A cross sectional study. BMJ Open. 2018;8:e020056. doi: 10.1136/bmjopen-2017-020056.
    1. Sikander S., Ahmad I., Atif N., Zaidi A., Vanobberghen F., Weiss H.A., Nisar A., Tabana H., Ain Q.U., Bibi A., et al. Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: A cluster randomised controlled trial in Pakistan. Lancet Psychiatry. 2019;6:128–139. doi: 10.1016/S2215-0366(18)30467-X.
    1. Rahman A., Malik A., Sikander S., Roberts C., Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. Lancet. 2008;372:902–909. doi: 10.1016/S0140-6736(08)61400-2.
    1. Rahman A., Akhtar P., Hamdani S.U., Atif N., Nazir H., Uddin I., Nisar A., Huma Z., Maselko J., Sikander S., et al. Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: A non-inferiority, randomized controlled trial. Glob. Ment Health. 2019;6:e8. doi: 10.1017/gmh.2019.7.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj