Fear of COVID-19 among pregnant women in Pakistan: a cross-sectional study

INTRODUCTION

The emergence of the COVID-19 pandemic has been a source of exaggerated fears, worries, and anxiety among individuals worldwide.¹ The fear and worry are directly related to infectivity, the medium of transmission, and its potential for associated morbidity and mortality.^2,3

In the last three decades, the pandemic of AIDS, SARS outbreak, menacing scenarios of an avian influenza pandemic, and the threat of biological weapons have increased the concern among health authorities, media, and the public. On January 30, 2020, COVID-19 was called a public health emergency of international concern (PHEIC) by WHO.⁴ Fear associated with COVID-19 affected individuals of every cadre of life leading to other psychosocial challenges like stigma, discrimination, and marginalization. With the greater intensity of fear, individuals often do not think clearly and logically when reacting to COVID-19.^1,3 Although the majority of patients affected by the disease will recover without any long-lasting consequences, many others will be affected due to social distancing, isolation, and ultimately depression. Current research in COVID-19 across the world has mostly emphasized infection control, timelines for an effective vaccine, management, and cure, but the psychosocial aspect has yet to be thoroughly studied and taken seriously.³

Researchers in China found in a study that 53.8% of the participants rated the psychological effect of the virus outbreak as moderate or severe. Another nationwide survey of more than 50,000 people in China revealed that about 35% of the respondents experienced psychological distress.⁵ During epidemics and pandemics concerns such as fear of death generally increase among patients, and feelings of loneliness and anger develop among people who are quarantined. Additionally, people who are quarantined lose physical connections and conventional social interactions.⁶

Pregnant women are considered a vulnerable group during the COVID pandemic, because of the physiological changes of pregnancy which make them more susceptible to infections in general. Previous studies have shown a higher risk of serious illness and mortality from viral infections during pandemics such as influenza and Ebola virus. Additionally, viral infections also increase the risk of spontaneous miscarriage and preterm birth .⁷

Researchers agree that women tend to experience increased psychosocial stress during pregnancy. A study of a diverse urban population revealed that 78% of women experienced low-to-moderate antenatal psychosocial stress, whereas high-level psychosocial stress was noted in 6% of cases.⁸ Some of the stress-inducing factors that affect women in pregnancy worldwide include inadequate resources, poor employment conditions, the stress of family and household responsibilities, challenges in intimate relationships, and pregnancy complications.8 Even though so far data from many studies suggest that pregnant women are not at an increased risk of contracting the virus or have a greater likelihood of complications, it is important to look for more evidence in this regard.⁹

Although fear is common in almost all sets of population, maternal and child health experts, researchers feel that pregnant women are found expressing much of the fear related to their course of pregnancy, the in-utero transmission of the disease, and questions related to infection control in healthcare settings. They have also expressed their concerns in clinics and in social education live sessions about the safety of having a healthy pregnancy in these times. These fears have a potential risk of putting at stake mental health during these times. In Pakistan, an increasing number of COVID-19 patients has raised concerns about the preparedness of health care systems to flatten the curve and an increase in massive anxiety levels in the public. Hence, the purpose of this paper was to explore the fears faced by pregnant women related to COVID-19.

METHODS

This was a cross-sectional study conducted among pregnant women attending the antenatal clinics of Aga Khan University Hospital main campus and its affiliated secondary care level hospital Kharadar campus. The purpose of choosing this site is to have a variety and convenience of sampling available. Kharadar campus is conducting more than 2300 deliveries per year. The major turnover of the patients in this setting is the low middle-income population of both urban and rural areas. Total study period was four months. The conception of the study started in April 2020 and the ethical review approval was sought in May 2020 (2020-4740-10509). The study was completed in the month of July 2020.

Sampling

Since there are no prior studies done on this phenomenon, we collected data from 200 pregnant women and explored their fear elements. Since in the times of COVID the physical and in-person interaction is limited all pregnant women registered in AKUH or secondary care hospitals were eligible. All those who did not give consent to participate in the study were excluded. The questionnaire was translated into the local language for those who cannot understand English and is explained to them by health care workers.

Data collection method

A survey form was made on google drive and was sent across to pregnant women by their obstetricians via WhatsApp. There was no face to face interaction or telephonic calls.

The contact details were retrieved from medical records. Data was collected by the physician consultants in their respective clinics using a google drive link. A verbal consent and a brief description of the project were given to participants and when they agreed. The link was shared with them. The data collection took only five minutes of their time. This fast track is adapted due to COVID-19 and limited in-person interaction. Their names personal details or medical record numbers are not being asked in the questionnaire to maintain the anonymity of identity.

Data collection tool

The data collection form was divided into two sections: a) Demographics and b) COVID fear form. A 7-item scale of “Fear in COVID” was used. This scale is developed by researchers from Iran and is validated on a sample size of 700.10 This is a Likert scale and the participants indicate their level of agreement with the statements choosing any response from “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree,” and “strongly agree”.

Data analysis plan

The data was analyzed using SPSS version 20. The analysis consisted of simple descriptive of central tendency, Pearson r correlation, and t-test.

RESULTS

This cross-sectional survey was carried out on 201 pregnant women mostly belonging to middle and low socioeconomic class. The majority (80%) of women were less than 30 years of age. Only 26 (12.9%) were primigravids, remaining were multigravidas of a different order of pregnancy Table 1.

More than 50% were in the second trimester, 25% were in the third trimester, and were near delivery.

Method of constructing fear level of Coronavirus-19: The using a 5-point likert scale ranging from 1(Strongly Disagree) to 5 (Strongly Agree). These scores can be added to obtain a total fear score. Total score ranges from 7 (minimal score) to 35 (maximal score). Scores for low anxiety range from 7-16; moderate anxiety from 17-26; and high anxiety from 27 to 35.

The majority (98%) were homemakers and the maximum education level was up to higher secondary school in 78% of women.

Household income was less than 55,000/- Pakistani rupees per month in 93% of households. The majority (88%) were healthy with no co-morbid however few had asthma and diabetes. We used the Likert scale for measuring the fear of coronavirus infection.

A 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (strongly agree) was used. These scores were added to obtain a total fear score ranging from 7 (minimal score) to 35 (maximal score). Scores for low fear ranged from 7-16; moderate fear from 17-26; and high fear from 27-35. Table 2 shows the intensity of fear of coronavirus among young pregnant women. 60% of our study population showed high fear scores (27-35) from coronavirus whereas another 30% had moderate fear. We also looked at the association of our study variables with the amount of fear of COVID-19 as shown in Table 3.

Although the majority of pregnant women scored high fear on the scale, there was no statistically significant difference in fear score in relation to the number of pregnancies or differences in pregnancy trimesters. There was no association of fear score with education level and household income. Our data do not support any association of co-morbid in pregnancy with fear as numbers are quite less.

DISCUSSION

The findings from the data elicit that 60% of the sampled population is undergoing a high level of fear with the COVID-19 pandemic during pregnancy. There could be several reasons for it. Contextually reflecting, Pakistani society is complex and majorly strewn across the divide of urban and rural populations. This divide comes along with diverse mindsets, viewpoints, cultural differences, and levels of education. The majority of pregnant women are ill-informed, lack the necessary resources to learn credible information and facts, and have limited access to healthcare professionals due to the quickly spreading virus.^11,12 Women are also prone to contracting infections during pregnancy due to modified immunity, thus more than 60% of the women surveyed revealed fear for their unborn child’s safety and were worried about visiting their obstetrician and missed essential antenatal visits.¹³ Many women have developed complications due to stress and anxiety but did not visit the hospital due to a high level of fear. More than a quarter of pregnant women randomly tested in a city in Pakistan came out positive for COVID-19, indicating a high level of contagion among pregnant women.¹⁴

We found mixed feelings of pregnant women regarding COVID-19 infection during the survey as reported in other studies from Pakistan.¹¹ More than 70% felt palpitations and feelings of sinking heart when they think about coronavirus. Women who have access to teleconsultation and professional healthcare reported ease in the spaced-out antenatal visits by their doctors. Women are, however, concerned about their health and that of their babies when they go for a delivery, which is their major challenge for now.¹²

The apprehensions are commonly due to the sensationalism in reporting news in the media.^11,15 Seventy-three percent of pregnant women in our survey reported nervousness and anxiety while watching the news or using social media. There is information overload, highlighting the failing healthcare system more often. Undermining positive health outcomes with COVID-19 infection in social media is one of the major contributory factors for increasing the level of stress and anxiety. While pandemic is novel and the people unable to respond proactively to the situation because of lack of preparedness, social media can play a strong role in creating optimism, and educate the masses on being responsible, compassionate and united.¹⁶

Women are experiencing all sorts of indicators of stress in their bodies.^17,18 Pregnant women have been reporting that thinking about the disease and the state of their vulnerability breaks them into a cold sweat. Women feel sweaty in the palms and jittery at the thought of contracting the virus. In our study, 65% of pregnant women reported clammy hands while thinking about getting coronavirus. About 72% reported insomnia and sleep disorders related to COVID-19 during pregnancy as reported by others.¹⁹ Pregnant women in Pakistan are also subject to neglect in most rural settings and frequently in urban households. Misleading information coupled with stress, poor maternal health, and limited prospects of timely medical intervention as well as fear and anxiety of contracting the virus during any unfortunate social interaction is becoming scary prospects for women and their families.^17,20 The cessation of social mobility has hampered many pregnant women, and due to the hormonal changes in pregnancy coupled with stress and anxiety over the isolation and uncertainty, pregnant women have been reported to have developed hypertension during pregnancy.^11,21

Overall maternal morbidity and mortality rates are among the highest in Pakistan. Pakistan is among the six countries that account for 50% of global deaths due to complications in pregnancy and birth.²¹ With the already unsatisfactory healthcare outcomes for women, in particular, the unprecedented burden of COVID-19 pandemic on healthcare could have a detrimental impact on pregnant women’s health and well-being. Coupled with the anxiety and stress build-up due to sensationalism in the media, pregnant and lactating women, in particular, have reported that their concerns and fears are growing during COVID-19.¹⁵ Fear of losing life due to coronavirus is reported by 68% of pregnant women in our study which indicates an out of proportion high level of stress. While pregnant women are worried about hospital visits, lactating mothers are deeply concerned about the well-being of their babies. The global health organization advisories CDC and UNICEF, need to implement various modes of communication for these women to alleviate their stress and anxiety and educate them on helpful tips and measures for prevention and care.^22,23 Reliable and credible information should be provided to women from hospitals and opportunities to get connected with their doctors over the phone and preferably over a video conference. Well-planned mass communication by government and media agencies would significantly help and support pregnant and lactating women during COVID-19.¹⁶

Due to the building stress and hormonal changes in women, many have reported insomnia or sleep-related problems during pregnancy in the wake of the coronavirus disease.²⁴ High-risk pregnancies and especially women approaching the end of their third trimester are reporting troubled sleep, restlessness, and increased unease due to their growing fears and apprehensions.¹¹ In our study we could not find any association of fear with trimester of pregnancy or gravidity. Also, there was no association between fear and the level of education and working status. However, 68.6% of pregnant women in our study verbalized that watching social media and television has increased their fear and stress.

Women are being advised to accept the challenges of the COVID-19 pandemic. Since they tend to become more stressed during pregnancy, they are advised to divert their thoughts, find productive pursuits, and continue to live life normally.²⁵ Pregnant women must be supported to develop resilience and a strong mindset in choosing to follow precautionary measures for their well-being and for that of others.²⁶

Hypertension and palpitations are often a response of the body to fear, anxiety, and stress. Pregnant women have reported hypertension and palpitations upon news of the quickly spreading virus; social distancing and isolation requirements due to symptoms similar to COVID-19; infected spouse or family member; death in the family, and other alarming news. The pandemic is a stressful time for most people and pregnant women seem to be more vulnerable among the cohorts including the elderly and children.^15,27 Doctors and healthcare experts advise limiting negativity and overload of information by balancing home routines with an activity of choice that can divert the mind towards productive outcomes.²⁵

Limitations

Due to the high COVID-19 surge pregnant woman from diverse settings could not be approached due to restrictions. Due to small sample size the results cannot be generalized. Another study with diverse population and bigger sample is recommended for future implications.

CONCLUSION

Our findings suggest a high level of fear of COVID- 19 infection among the pregnant population with a higher level of anxiety and stress related symptoms. They are worried about their health as well as the health of their newborn babies. The amount of fear and stress is independent of the trimester or order of pregnancy. Better counselling and telehealth clinics are the way forward for these women. The government along with many hospitals and healthcare organizations has launched Telehealth Programs and helplines for women and people in general, to consult about symptoms, treatment, and prevention. Pregnant women should be advised not to ignore persisting symptoms of physical or mental ill-health and consult the healthcare provider at an early stage to prevent any complications which can result in adverse pregnancy outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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