Abstract
Background:
The pandemic of COVID-19 affected seriously the health of pregnant women. Pregnant women and their fetuses are considered high-risk populations. Spirituality may enhance the adaptability to illnesses.Objectives:
This study aimed to determine the relationship between spiritual health and anxiety caused by COVID-19 in pregnant women referred to Chabahar health centers in Iran.Methods:
In this descriptive-correlational study, 198 pregnant women participated in 2020 - 2021. Data were collected using Polutzin and Ellison Spiritual Well-Being Scale (SWBS) and the Coronavirus Anxiety Scale Questionnaire (CDAS2).Results:
The analysis finds that the mean anxiety score in pregnant women was severe (mean = 32.05; SD = 9.59). Spearman correlation test did not show a linear relationship between spiritual health and COVID-19 anxiety (P > 0.05).Conclusions:
There is probably no link between spirituality and severe anxiety caused by COVID-19. Therefore, it is appropriate to find out other influential factors in cases of severe stress in acute crises.Keywords
Anxiety COVID-19 Descriptive-Correlational Study Pregnancy Spirituality
1. Background
The pandemic of COVID-19 disease has caused a lot of stress and anxiety in communities (1). People show any anxious behaviors since January 20, 2020, when China confirmed the human-to-human transmission of disease (2). COVID-19 anxiety is common and often occurs due to a lack of knowledge and scientific information, and ambiguity in people about the virus (3). Various stressors harm coping mechanisms. In an infectious disease, pregnant women and their fetuses are more vulnerable and high-risk people compared to others (4, 5) and are at risk for severe respiratory illness, stress, fear, and anxiety (5). Studies show that excessive fear during pregnancy is associated with increased cesarean section, premature birth, low Apgar score, low birth weight, cardiac dysrhythmia, and increased near-term mortality (6-8). Dysfunction of the hypothalamic-pituitary-adrenal axes and the symptoms of depression in adolescence, and asthma in children, are other side effects of stress during pregnancy (9).
According to studies, spiritual health is a factor that can reduce anxiety. In times of crisis, spirituality is a powerful resource that is a serious barrier to coping with stress and anxiety. Patients whose spiritual health is enhanced can effectively adapt to their illness (10). Although enormous studies have been done since the COVID-19 pandemic, there is still a paucity to show the relationship between COVID-19 anxiety and spirituality during pregnancy.
2. Objectives
This study evaluated the association between COVID-19 anxiety and spirituality in pregnant women in a region in Iran.
3. Methods
The present descriptive-correlation study was performed on 198 pregnant women in 2021 referring to Chabahar health centers, Iran. The data were collected using the convenience sampling method after obtaining the ethics code (IR.ZBMU.REC.1400.054) from Zabol University of Medical Sciences, Iran, and the clients’ consensus. The study samples were pregnant women who were referred to health centers for prenatal care and voluntarily participated in the study. Inclusion and exclusion criteria include having no history of significant psychiatric disorders, no severe physical problems, no complications during pregnancy such as preeclampsia, eclampsia, chorioamnionitis, decolonization, and abnormal fetal heart rate, not using substances or drugs that affect stress and anxiety, and having no significant loss in six months ago.
The data were collected using three questionnaires, including (a) demographic characteristics including age, occupation status, education level, place of residence, and pregnancy history (number of live children, number of pregnancies and deliveries, type of previous delivery, preferred method of current delivery); (b) Coronavirus Anxiety Scale Questionnaire (CDAS2), which measures COVID-19 anxiety. Coronavirus Anxiety Scale Questionnaire measures physical and psychosocial symptoms of covid-19 anxiety with 18 four points Likert-type items. Higher scores indicate a higher level of anxiety. The CDAS2 Cronbach’s alpha was 0.95 (11). The Spiritual Well-Being Scale (SWBS) measures religious and existential well-being with 20 Likert-type items from strongly disagree to strongly agree. Higher scores indicate higher spiritual well-being. The SWBS Cronbach’s alpha was greater than 0.85 (12). Data were analyzed using SPSS 23. A P-value less than 0.05 was set as statistically significant.
4. Results
The present study was performed on 198 pregnant women in health centers. The mean age of the subjects was 26.53 ± 6.36 years, and 94.9% of the pregnant women were housewives. About 51% of women had undergraduate education, 28.3% had a diploma, and 19.7% had postgraduate education and higher. The highest level of education of pregnant women was in primary and secondary school (38.4%), 41.5% of the spouses had undergraduate education, 36.4% had a diploma, 20.3% had a postgraduate education and higher, the highest level of education of the spouses was in the diploma level (36.4%). About 97% of pregnant women lived in the city in terms of residence and half of the pregnant women studied in the previous pregnancy had given birth naturally (51.5%) and in the current delivery tended to have a normal delivery (50.5%). Only a small number of women chose cesarean section for various reasons due to obstetrics (11.6%) and 30% were still hesitant about their delivery method. About 93% of women made prenatal visits and observed social distance (96.5%). About 63% of women followed health protocols related to quarantine and 32.3% of people used to travel with their parents and relatives during the epidemic. Only 4% of women continued to travel as before the coronavirus. About 95% of women wore masks (Table 1). The pregnant women’s anxiety scores were severe, and their psychological symptoms were higher compared with their physical symptoms. The mean score of the spiritual health of pregnant women was also high. Table 2 shows that the Spearman correlation test did not show a linear relationship between spiritual health and anxiety caused by COVID-19 (P = 0.501).
Demographic Profile of Pregnant Women
| Variables | No. (%) |
|---|---|
| Mother education | |
| Non-educated | 26 (13.1) |
| Primary and secondary | 76 (38.4) |
| Diploma | 56 (28.3) |
| Associated degree | 15 (7.6) |
| Bachelor | 17 (8.6) |
| Masters and above | 8 (4.0) |
| Spouse education | |
| Non-educated | 30 (15.2) |
| Primary and secondary | 52 (26.3) |
| Diploma | 72 (36.4) |
| Associated degree | 12 (6.1) |
| Bachelor | 17 (8.6) |
| Masters and above | 15 (7.6) |
| Job | |
| Housewife | 189 (94.9) |
| Worker | 10 (5.0) |
| Address | |
| City | 193 (97.5) |
| Village | 5 (2.5) |
| Type of previous delivery | |
| NVD | 102 (51.5) |
| C/S | 32 (16.2) |
| None* | 61 (30.8) |
| No mentioned** | 3 (1.5) |
| Current delivery | |
| NVD | 100 (50.5) |
| C/S | 23 (11.6) |
| None* | 61 (30.8) |
| No mentioned** | 14 (7.1) |
| Has your desire for a particular type of labor changed since the COVID-19 epidemic? | |
| Yes | 2 (1.0) |
| No | 196 (99.0) |
| Prenatal visit | |
| Yes | 185 (93.4) |
| No | 14 (6.6) |
| Social distance | |
| Yes | 191 (96.5) |
| No | 7 (3.5) |
| During the last few months after the COVID-19 epidemic, which of the following have you observed? | |
| Quarantine | 124 (62.6) |
| Travel relatives only | 64 (32.3) |
| Travels before the COVID 19 | 10 (5.0) |
| Using mask | |
| Yes | 189 (95.5) |
| No | 9 (4.5) |
Mean, Standard Deviation, and Correlation Coefficient of the Main Research Variables
| Variables | Mean ± SD | Correlation Coefficient (SH) |
|---|---|---|
| Anxiety score | 32.05 ± 9.59 | r = -0.048, P > 0.05 |
| Psychological anxiety | 18.95 ± 6.04 | r = -0.040, P > 0.05 |
| Physical anxiety | 13.09 ± 4.70 | r = -0.070, P > 0.05 |
| Spiritual health score (SH) | 103.74 ± 11.20 | r = 1.000 |
5. Discussion
The COVID-19 pandemic causes catastrophic effects on societies. People in communities have experienced many physical and psychological problems. Religious beliefs act as a shield against stressors in life. This study evaluated the association between spirituality and COVID-19 anxiety COVID-19 in pregnant women. The results did not show any significant relationship between them.
A high level of anxiety declines the immune system function and acts as a backbone to help the virus overcome the health of the person (13). Women’s mental health during pregnancy is influenced by factors such as feelings about femininity, marital life, the spouse’s family, as well as feelings about agreements and conflicts, sexuality, and wanting or not wanting a child. Pregnancy and childbirth have an inevitable effect on women’s bodies and minds (14). Previous studies report a range of 12.5% to 90% anxiety in pregnant women (14, 15). The level of anxiety in pregnant women concerning COVID-19 is very high (16), which is consistent with the present study. Iranian pregnant women have a high prevalence of anxiety in the third trimester of pregnancy (17). The level of anxiety increases with bad and disappointing news about COVID-19 (15).
Moreover, spirituality is related to adaptation ability, expectancy, ability to find the meaning of life in diseases and better adaptation to stressful events (18). The previous studies indicate a statistically significant relationship between high levels of spiritual health and mental health variables (19, 20). However, a study shows no significant correlation between spiritual health and morbid anxiety (21). In the present study, although the spiritual health of pregnant women is at a high level, it did not reduce their anxiety. Religions are expected to increase the quality of life, however, some beliefs that may not emerge from religions but may be known as religious beliefs such as postponing to follow conventional treatment methods or avoiding preventive methods negatively affect people’s health (22).
This study explored pregnant women’s anxiety about COVID-19 and their spiritual health which could be a strength; however, the data were collected at some healthcare centers in a city, which limits the generalizability of findings.
To sum up, COVID-19 anxiety level is high in pregnant women and despite the high level of spirituality; there was not a linear association between the two factors. This may suggest that spirituality cannot correlate with a high level of anxiety during pregnancy. This can lead to pregnant women becoming overly concerned about the health of their fetus, fearing that the fetus will be infected with the coronavirus, and fearing losing the fetus and dying. All of this causes mental disorders in pregnant women and increases their fear and anxiety. During the COVID-19 pandemic, it is recommended to carefully consider the severe anxiety of pregnant women and to offer other measures to reduce it. Different contexts and factors help people to overcome this pandemic safely. Providing accurate and appropriate information on preventive approaches, following health recommendations and cognitive-behavioral therapies, and distance education along with spirituality might help overcome COVID-19 anxiety.
References
-
1.
Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395(10228):931-4. [PubMed ID: 32164834]. [PubMed Central ID: PMC7158572]. https://doi.org/10.1016/S0140-6736(20)30567-5.
-
2.
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. [PubMed ID: 32325383]. [PubMed Central ID: PMC7152913]. https://doi.org/10.1016/j.psychres.2020.112954.
-
3.
Bajema KL, Oster AM, McGovern OL, Lindstrom S, Stenger MR, Anderson TC, et al. Persons Evaluated for 2019 Novel Coronavirus - United States, January 2020. MMWR Morb Mortal Wkly Rep. 2020;69(6):166-70. [PubMed ID: 32053579]. [PubMed Central ID: PMC7017962]. https://doi.org/10.15585/mmwr.mm6906e1.
-
4.
Liu H, Wang LL, Zhao SJ, Kwak-Kim J, Mor G, Liao AH. Why are pregnant women susceptible to COVID-19? An immunological viewpoint. J Reprod Immunol. 2020;139:103122. [PubMed ID: 32244166]. [PubMed Central ID: PMC7156163]. https://doi.org/10.1016/j.jri.2020.103122.
-
5.
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15. [PubMed ID: 32151335]. [PubMed Central ID: PMC7159281]. https://doi.org/10.1016/S0140-6736(20)30360-3.
-
6.
Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, et al. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis. 2020;20(5):559-64. [PubMed ID: 32220284]. [PubMed Central ID: PMC7158904]. https://doi.org/10.1016/S1473-3099(20)30176-6.
-
7.
Elwood C, Boucoiran I, VanSchalkwyk J, Money D, Yudin M, Poliquin V. SOGC Committee Opinion – COVID-19 in Pregnancy. J Obstet Gynaecol Can. 2020. https://doi.org/10.1016/j.jogc.2020.03.012.
-
8.
Chen Y, Wu L, Zhang W, Zou L, Li G, Fan L. Delivery modes and pregnancy outcomes of low birth weight infants in China. J Perinatol. 2016;36(1):41-6. [PubMed ID: 26540243]. https://doi.org/10.1038/jp.2015.137.
-
9.
Hasan Zadeh Lif Shagerd M, Tarkhan M, Taghi Zadeh ME. [Effectiveness of stress inoculation training on perceived stress in pregnant women with infertility]. J Holist Nurs Midwifery. 2013;23(2):27-34. Persian.
-
10.
Garfin DR, Silver RC, Holman EA. The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure. Health Psychol. 2020;39(5):355-7. [PubMed ID: 32202824]. [PubMed Central ID: PMC7735659]. https://doi.org/10.1037/hea0000875.
-
11.
Alipour A, Ghadami A, Alipour Z, Abdollahzadeh H. [Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in the Iranian sample]. Health Psychol. 2020;8(32):163-75. Persian. https://doi.org/10.30473/hpj.2020.52023.4756.
-
12.
Biglari Abhari M, Fisher JW, Kheiltash A, Nojomi M. Validation of the Persian Version of Spiritual Well-Being Questionnaires. Iran J Med Sci. 2018;43(3):276-85. [PubMed ID: 29892145]. [PubMed Central ID: PMC5993904].
-
13.
Yao H, Chen JH, Xu YF. Rethinking online mental health services in China during the COVID-19 epidemic. Asian J Psychiatr. 2020;50:102015. [PubMed ID: 32247261]. [PubMed Central ID: PMC7271098]. https://doi.org/10.1016/j.ajp.2020.102015.
-
14.
Karami K, Mardani A. [Relationship between Mental Health and Quality of Life in Pregnant Women]. Q J Health Breeze. 2014;2(1):10-7. Persian.
-
15.
Xiao H, Zhang Y, Kong D, Li S, Yang N. Social Capital and Sleep Quality in Individuals Who Self-Isolated for 14 Days During the Coronavirus Disease 2019 (COVID-19) Outbreak in January 2020 in China. Med Sci Monit. 2020;26. e923921. https://doi.org/10.12659/msm.923921.
-
16.
Abedzadeh-Kalahroudi M, Karimian Z, Nasiri S, Khorshidifard MS. [Anxiety and perceived stress of pregnant women towards Covid-19 disease and its related factors in Kashan (2020)]. Iran J Obstet Gynecol Infertil. 2021;24(5):8-18. Persian. https://doi.org/10.22038/ijogi.2021.18567.
-
17.
Alipour Z, Lamyian M, Hajizadeh E. [Anxiety during pregnancy: A risk factor for neonatal physical outcome?]. Nurs Midwifery J. 2011;9(1):30-8. Persian.
-
18.
Forouhari S, Hosseini Teshnizi S, Ehrampoush MH, Mazloomy Mahmoodabad SS, Fallahzadeh H, Tabei SZ, et al. Relationship between Religious Orientation, Anxiety, and Depression among College Students: A Systematic Review and Meta-Analysis. Iran J Public Health. 2019;48(1):43-52. [PubMed ID: 30847310]. [PubMed Central ID: PMC6401585].
-
19.
Taghiabadi M, Kavosi A, Mirhafez SR, Keshvari M, Mehrabi T. The association between death anxiety with spiritual experiences and life satisfaction in elderly people. Electron Physician. 2017;9(3):3980-5. [PubMed ID: 28461873]. [PubMed Central ID: PMC5407231]. https://doi.org/10.19082/3980.
-
20.
Borreani C, Alfieri S, Farina L, Bianchi E, Corradini P. Fear of cancer recurrence in haematological cancer patients: exploring socio-demographic, psychological, existential and disease-related factors. Support Care Cancer. 2020;28(12):5973-82. [PubMed ID: 32285261]. https://doi.org/10.1007/s00520-020-05434-9.
-
21.
Hosseini Poor Abardeh FS, Niknam M. [The Relationship Between Spiritual Health With Existential Anxiety and Morbid Anxiety in Female Patients With Breast Cancer]. J Arak Uni Med Sci. 2021;24(3):360-71. Persian. https://doi.org/10.32598/jams.24.3.5952.2.
-
22.
Aksoy Derya Y, Altiparmak S, Akca E, Gokbulut N, Yilmaz AN. Pregnancy and birth planning during COVID-19: The effects of tele-education offered to pregnant women on prenatal distress and pregnancy-related anxiety. Midwifery. 2021;92:102877. [PubMed ID: 33157497]. [PubMed Central ID: PMC7831526]. https://doi.org/10.1016/j.midw.2020.102877.