INTRODUCTION
Pregnancy can affect women’s mental health. A meta-analysis revealed that the prevalence of anxiety disorder diagnosis in pregnant women is 15.2%, but pregnancy-related anxiety (PRA) is common during the prenatal and postnatal periods [1,2]. PRA involves anxiety across nine dimensions including fetal and maternal health, loss of fetus, childbirth, body image, parenting, social and financial support, and healthcare issues. It is characterized by three critical attributes (affective responses, cognitions, and somatic symptoms), three antecedents (a real or anticipated threat to pregnancy or its outcomes, low perceived control, and excessive cognitive activity), and four consequences (negative attitudes, difficulty concentrating, excessive reassurance-seeking behavior, and avoidance behaviors) [3]. According to a systematic review, the prevalence of PRA in low-and middle-income countries ranged from 1% to 26% [4]. Studies in Iran reported anxiety prevalence rates ranging from 32.5% to 40% among pregnant women [5,6]. A study indicated that the magnitude of geographic disparities in measuring PRA varies from 23.8% in the United States to 6.7% in Iran and Canada [7].
The epidemic of infectious diseases, such as the coronavirus disease-2019 (COVID-19) epidemic, affects not only the physical health of patients but also the mental health and well-being of the non-infected population. Health anxiety was a major contributor to poor mental health, which led to difficulty in daily life, feelings of hopelessness, trouble sleeping, and the experience of unusual physical symptoms. Some people developed a specific condition known as COVID-19 anxiety syndrome, characterized by obsessive-compulsive and maladaptive behaviors [8]. Previous studies have demonstrated that outbreaks of new infectious diseases, such as acute respiratory syndrome, can elevate levels of anxiety, depression, and stress across the population [9,10]. A World Health Organization report indicated a 25% increase in the global prevalence of anxiety and depression during the COVID-19 pandemic [10]. Females and younger adults at reproductive age reported higher anxiety levels compared to males and the elderly [9]. The outbreak represented a unique stressor that significantly influenced pregnant women’s mental health and exacerbated PRA [11]. The increase was linked to concerns about fetal and family members’ well-being, social restrictions, and changes in daily routines and prenatal care, culminating in a bio-psycho-socio-economic crisis [12]. A web-based study on Iranian pregnant women showed that nearly a quarter of them experienced PRA during the pandemic, with COVID-19 anxiety being a significant predictor of PRA [13].
PRA leads to affective responses, cognitions, and somatic symptoms. Common physical presentations include sleep problems such as insomnia, nightmares, sleep latency, and disturbances [3]. Moreover, sleep disturbance is a risk factor for anxiety during pregnancy [13]. Sleep disturbances commonly occur in pregnant women from the first to the last trimester. Insomnia was notably prevalent in the third trimester [14]. Issues such as frequent urination, heartburn and reflux, restless legs syndrome, back pain, and sleep apnea are associated with changes in sleep patterns [15]. Studies have indicated that the COVID-19 pandemic worsened sleep quality in the general population and exacerbated it in pregnant women [16,17].
The concurrent occurrence of PRA and sleep disturbances during pregnancy, along with the COVID-19 pandemic, may impact the mental health of pregnant women and increase their vulnerability compared to the general population and non-pregnant women. Few studies have explored sleep quality and COVID-19-related anxiety across different pregnancy trimesters and compared results with non-pregnant women. Therefore, this study aimed to compare sleep quality and anxiety related to Coronavirus disease in pregnant and non-pregnant women.
METHODS
Study Design and Participants
This case-control study was conducted from April to October 2022 in Shiraz, Iran. Based on studies by Huang and Zhao [18] and Ayaz et al. [19], the sample size was calculated to achieve α=0.5 and 80% power, resulting in a minimum of 40 study participants; additionally, to accommodate a 20% sample loss, 50 samples were considered. To conduct subgroup analyses each trimester and allow comparisons of pregnant women in each trimester with non-pregnant women, the sample size for pregnant individuals was set at 35 per trimester, thus including 105 pregnant and 50 non-pregnant participants.
The case group comprised married pregnant women in any trimester without high-risk conditions such as stillbirth, ectopic or molar pregnancies, recurrent abortion, dystocia, neonatal anomalies, dead fetus, or pregnancies complicated by preeclampsia, diabetes, intrauterine growth restriction, preterm rupture of membranes, oligohydramnios, polyhydramnios, or placenta previa. Additionally, they had no history of infertility or pregnancies resulting from infertility treatments. The control group consisted of non-pregnant women of reproductive age, free of chronic conditions like cancer, diabetes, lupus erythematosus, hypertension, etc. Neither group exhibited anxiety or psychological disorders, or sleep disorders that were being treated at the study’s onset. Exclusion criteria included withdrawal post-questionnaire completion or incomplete questionnaires. The study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1400.002). Written informed consent was obtained from all participants. The rights to voluntary participation and study withdrawal were upheld, without any alteration to the participants’ care. Confidentiality of data was ensured.
Measures
Demographic and clinical data for both groups were gathered using a researcher-designed questionnaire. Sleep quality was evaluated with two tools: a single-item sleep quality scale (SQS) and the Pittsburgh Sleep Quality Index (PSQI) [19,20]. The SQS is a self-report tool employing a discretized visual analog scale where participants rate their overall night-time sleep quality over the past 7 days on a scale from 0 to 10. Sleep quality for participants was categorized as follows: 0=terrible, 1–3=poor, 4–6=fair, 7–9=good, and 10=excellent [20].
The PSQI, a self-administered instrument, evaluated sleep quality over the preceding month through a 19-item questionnaire. It covers seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Each item is scored on a 4-point Likert-type scale, ranging from 0 (no difficulty) to 3 (severe difficulty). The total score ranges from 0 to 21, where a higher score denotes poorer sleep quality. Scores under 5 signify good sleep quality, 5 to 11 mild problems, 11 to 16 moderate problems, and 17 to 21 severe problems [21]. The Persian version of the PSQI was utilized for this study [22].
COVID-19-related anxiety was assessed using the Corona Disease Anxiety Scale (CDAS) in Iranian samples. This questionnaire includes 18 items, each scored on a 4-point Likert scale (never=0, sometimes=1, frequently=2, always=3). Totals range from 0 to 54, with higher scores indicating greater anxiety levels [23].
Statistical Analysis
Quantitative and qualitative variables are presented as mean± standard deviation and frequency (percentage), respectively. The Shapiro-Wilk test was applied to assess normality. Mean comparisons between the groups were conducted using the independent t-test. Analysis of variance, along with pairwise comparisons using a post-hoc test, was employed to compare means across multi-level variables. Quantitative variables were correlated using Pearson’s correlation test in the case of normality and Spearman’s test otherwise, while the association of qualitative variables with pregnancy and non-pregnant state was examined using the chi-square test. Data analysis was performed with SPSS software version 22 (IBM Corp., Armonk, NY, USA). A p-value<0.05 was deemed significant.
RESULTS
The sociodemographic and COVID-19 infection characteristics of the participants are detailed in Table 1. There were no significant differences between the case and control groups regarding age, history of COVID-19 infection, hospital admission, symptoms, or family history of the infection and related deaths (Table 1). No significant differences were found concerning gravidity (p=0.781), parity (p=0.745), history of abortion (p=0.869), infertility (p=0.818), or the nature of pregnancy—wanted or unwanted—across different trimesters in the case group (p=0.926).
The mean CDAS scores were 18.41±6.90 and 15.68±9.23 for pregnant and non-pregnant women, respectively (p=0.041). There was no significant variance in COVID-19-related anxiety across the trimesters in pregnant women (p=0.304), although the highest mean was observed in the third trimester (19.48± 6.96) compared to the first (18.77±5.78) and second trimesters (17.00±7.79). There was no significant difference in the mean sleep quality scores, as measured by the PSQI, between the case (6.74± 3.35) and control groups (6.38±3.25) (p=0.4). Analysis of variance revealed no significant difference in sleep quality scores among different pregnancy trimesters (p=0.095), although the mean score for the third trimester (7.34±3.10) was higher than that for the first (5.77±3.40) and second trimesters (6.02± 3.12). Comparison of sleep quality according to the SQS showed no significant differences between the two groups (p=0.642) or among different trimesters in the case group (p=0.319), yet approximately 62% of pregnant women compared to 50% of non-pregnant women reported fair to terrible sleep quality.
COVID-19-related anxiety was significantly correlated with undergoing a COVID-19 diagnostic test (p=0.026), hospital admission (p<0.001), and having a family member with a COVID-19 infection (p<0.001). However, sleep quality was only significantly correlated with having a family member with a COVID-19 infection (p=0.025) (Table 2).
Significant variables from the univariate analysis were selected as candidates for inclusion in the final model. In this model, the effects of pregnancy on COVID-19-induced anxiety and sleep quality were assessed by controlling for and adjusting other confounding variables. The findings indicated that pregnancy, hospitalization, and family infection with COVID-19 significantly influenced anxiety levels after adjusting for other confounders, with pregnant women reporting an average anxiety score 2.9 units higher than non-pregnant women. Additionally, conditions of hospitalization and family illness were associated with increased anxiety among the groups. However, neither pregnancy nor family infection with COVID-19 significantly affected sleep quality after adjusting for confounding variables (Table 3).
There was a significant correlation between anxiety and poor sleep quality based on the PSQI (r=0.270, p=0.005), and sleep quality as per SQS (r=-0.198, p=0.043) in pregnant women. This relationship was not observed in non-pregnant women.
DISCUSSION
The study found a statistically significant difference in the average scores of COVID-19-related anxiety between pregnant and non-pregnant women, with pregnant women in their third trimester experiencing the highest levels of anxiety. However, no difference in sleep quality was noted between the two groups.
Previous studies on respiratory pandemics such as severe acute respiratory syndrome and Middle East respiratory syndrome have shown that social isolation and disruptions in healthcare provision can negatively impact mental health [18]. A study revealed that nearly a fifth of the 10754 participants from 31 provinces in Iran suffered from severe or very severe anxiety during the COVID-19 outbreak, with women experiencing twice the anxiety levels of men [24]. In the current study, pregnant women reported higher levels of COVID-19-related anxiety compared to non-pregnant women. These findings align with those of Tomfohr-Madsen et al. [25], who, in a meta-analysis, found that 25.6% and 30.5% of pregnant women experienced depression and anxiety during COVID-19, respectively. However, these studies primarily examined general anxiety within the pregnant population without comparing it to non-pregnant women. Evidence suggests that the most prevalent triggers of depression and anxiety among pregnant women include worries about COVID-19-related threats to maternal and fetal health, concerns over inadequate prenatal care, and the effects of limited social interaction and isolation [26,27].
In this study, the mean anxiety score related to COVID-19 during the third trimester was higher compared to other pregnancy trimesters. As delivery approaches, maternal anxiety appears to increase. This was corroborated during the COVID-19 outbreak by Yue et al. [28], who demonstrated that anxiety levels in pregnant women in their third trimester were higher than those in the general population (both pregnant and non-pregnant) before the pandemic, and similar to the anxiety experienced by healthcare providers in hospitals admitting COVID-19 patients. Pregnant women are susceptible to anxiety and unpleasant emotions, and as fetal growth peaks in the third trimester, physical discomfort, fear of childbirth, and concerns for the baby’s health lead to significant psychological distress for the mother. Simultaneously, the secretion of adrenocortical hormones rises in pregnant women, increasing susceptibility to anxiety [18,29]. Additionally, the specific psychological pressures of the COVID-19 pandemic further elevate anxiety levels in mothers during the third trimester of pregnancy.
Results indicated that the average sleep quality score did not differ significantly between pregnant and non-pregnant women, though both groups encountered mild sleep quality issues according to PSQI scores. The average sleep quality score among pregnant women was greater than that of non-pregnant women, particularly in the third trimester. Çolak et al. [30] demonstrated that the COVID-19 pandemic has negatively impacted sleep quality, worsening as pregnancy progresses. Changes in daily life, social interactions, and hygiene habits due to COVID-19, along with hormonal and physiological changes and respiratory and gastrointestinal issues caused by fetal growth, led to more pronounced sleep issues in the third trimester. The current study found no difference in the frequency of sleep quality issues between the two groups; however, three-fifths of pregnant women, compared to half of the non-pregnant women, reported poor sleep quality. These findings coincide with those of Alan et al. [31], who reported that 88% of pregnant women experienced poor sleep quality in the early months of the pandemic. It appears that studies conducted during the initial outbreak waves revealed higher instances of deteriorated sleep quality, likely due to high mortality rates, increased contagion, and the absence of preventative and protective measures during this period.
Results from this study revealed that, in addition to pregnancy, hospital admissions due to COVID-19 and family members infected with COVID-19 significantly influenced anxiety levels. Hospitalization, often required in more severe cases, appears to impact the level of anxiety people perceive. This correlation was corroborated by Tan et al. [32], whose research indicated that hospitalized patients with COVID-19 infection experienced notably high anxiety due to significant disruption in psychosocial function. Furthermore, family member infection was a significant factor in high anxiety, corroborating findings by Khubchandani et al. [33], which indicated that symptoms of depression, anxiety, or both were significantly higher among individuals with an infected family member or friend, or whose family members were hospitalized. Several studies suggest that this psychological distress stems from numerous factors, including the burden of caregiving, uncertainty about disease outcomes, fear of losing loved ones, inadequate support from service providers, financial constraints, and restrictions on visiting family members, especially those in intensive care units [34-36].
This study demonstrated a relationship between COVID-19-induced anxiety levels and poor sleep quality among pregnant women, as measured by the PSQI and SQS. Higher anxiety levels were associated with poorer sleep quality. This association was also noted by Robillard et al. [37], who found that elevated stress and anxiety correlated with increased sleep disorders, not only in pregnant women but also in the general population. Moreover, Lin et al. [38] reported that even mild symptoms of anxiety and depression were strongly linked to poor sleep quality among pregnant women during the COVID-19 pandemic.
This study exclusively compared sleep quality and COVID19-related anxiety between pregnant and non-pregnant women, excluding the post-partum period. The sample included a limited number of women in different pregnancy trimesters due to research constraints during the COVID-19 pandemic, yet the study maintained acceptable power. Focused on self-reported questionnaires, the study assessed COVID-19-related anxiety but could not determine causality typically unestablishable through case-control studies.
Relative to non-pregnant women, pregnant women experienced higher levels of COVID-19-related anxiety, with the highest anxiety scores reported in the third trimester. Although both pregnant and non-pregnant women experienced mild sleep quality issues, there was no statistically significant difference in sleep quality between the two groups. Being pregnant, hospitalized due to COVID-19, or having a family member infected with COVID-19 were all associated with higher anxiety levels.
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