Dear Editor,
Coronavirus disease (COVID-19) is caused by a new virus from the coronavirus family, which first appeared in late December 2019 in Wuhan Province, China (1). The virus was officially announced by China on January 20, 2020, and then spread rapidly to other countries throughout the world (1). Following the spread of the virus, its negative physical and psychological effects gradually emerged. Through the years, experiences of the world in the face of the crises caused by plague pandemics over several different years (2), Spanish flu in 1918 (3), severe acute respiratory syndrome (SARS) in 2002 (4), H1N1 in 2009 (5), middle-east respiratory syndrome (MERS) in 2012 (6), and Ebola virus disease (EVD) in 2014 (7) indicate the psychological, physical, economic, and social effects of pandemics on people. All the studies investigating the issue of pandemics have indicated that vulnerable groups suffer more anxiety than others (2-7).
Pregnant women are among the most vulnerable groups during pandemics due to various physical and psychological reasons (3-6). Pregnancy causes immunological, physiological, and psychological changes in women. Studies have shown that pregnant women are prone to respiratory infections (8, 9). Numerous specific issues of pregnancy, symptoms, physical changes, body fitness, physiological, social, and emotional changes, financial problems, parental worries, relationships with others, body image and medical problems, anxiety about childbirth, and worries about the health of the baby can be mentioned as important psychological issues and a source of stress in pregnant women (10). Any stressful issue, exacerbation of stress, anxiety caused by pregnancy, and fear of the COVID-19 pandemic can affect the health of mothers and babies (11). Prenatal stress can influence many physical, mental, and social dimensions of pregnant women and the unborn baby’s health, increasing the risk of autism and brain developmental disorders, schizophrenia, obesity, insulin resistance, hypertension, preterm delivery, low birth weight, gestational diabetes, preeclampsia, hyperemia, lack of follow-up prenatal care, and mental disorders at birth (12, 13). Additionally, there are many factors that can influence pregnant women’s health during the COVID-19 era, such as fear of contracting the virus, the risk of vertical transmission of the infection to the infant, enhanced risk of human-to-human infection transmission, reduction of social support due to social distancing regulations, limited daily or part-time activities, being required to be at work, fear of the closure of medical and non-medical facilities, low level of education, financial problems, lack of accurate information and misinformation about COVID-19, the spread of the virus across the residential area, and concerns about being poisoned with disinfectant solutions (14, 15). A study investigated perinatal depressive and anxiety symptoms during the COVID-19 outbreak among 4124 pregnant women in 25 hospitals in 10 Chinese provinces. It was mentioned in this study that the crisis caused by the COVID-19 could be a risk factor for psychological disorders in pregnant women; Therefore, the provision of psychological interventions may be particularly useful to prevent destructive outcomes in women, fetuses, and infants (16). Another retrospective study on the impacts of infectious diseases like SARS in 1184 pregnant women reported stress, anxiety, and depression as risk factors for mothers’ and their infants’ health (17). Another study investigated the perception of pregnant women about the SARS epidemic and its impacts on them in Hong Kong. In the recent study, 980 pregnant women were examined, and the prevalence of anxiety among pregnant women was reported to be high and related to their social, economic, and physical health factors. Moreover, this study emphasized the role of midwives in the psychological adjustment of pregnant women (18)
According to the national guide for midwifery and childbirth services in Iran in 2016, the mental health examination of pregnant women is advised during the provision of prenatal care at the 6 - 10th, 16 - 20th, 31 - 34th, 35 - 37th, and 38 - 40th weeks of pregnancy to check the mother’s complete history and especially, the risk factors of psychological problems, psychiatric disorders, and domestic violence (19). However, due to the recent critical situation of the COVID-19 pandemic, the World Health Organization has suggested close physical and mental health screening for pregnant women at shorter intervals (20). Among the important reasons for shorter screening intervals in critical situations, some are more important than others, like mental health before pregnancy and before the onset of the crisis, current physical health status, number of children, planned or unplanned pregnancy, history of domestic violence, previous experiences of crises, and prior pregnancy experiences, history of infertility, access to social support, place of residence, economic situation, familial relationships, and the most important, history of contact with a person infected with the COVID-19 (19, 21). Considering the importance of mental health during the epidemic period, some countries have launched preventive and therapeutic interventions for mental disorders. The successful experiences of psychological interventions during epidemics such as SARS and influenza accelerated the implementation of instructions for starting psychological interventions during the COVID-19 pandemic (3, 4). Accordingly, China was the first country to take extensive measures in this area. Setting up mental health teams, training medical staff, providing professionals with specific guidelines and articles for different groups of people, broadcasting educational packages and videos for the general public in the national media, conducting appointments and counseling about self-care on the phone, and establishing online or in-person mental health screening centers during the COVID-19 pandemic (22). These measures were provided to all people, especially vulnerable ones. A study in China reported that psychological interference based on dialectical behavior therapy reduced depression, anxiety, and stress in a pregnant woman during late pregnancy and early childbirth (23).
In Iran, on February 19, 2020, the Ministry of Health officially announced the entry of the COVID-19 disease to the country (24). Afterward, extensive actions were performed to prevent and control the disease. In the field of mental health management, mental health teams were formed to improve the mental health of the general public (25-27). In order to protect pregnant women, the hospitals receiving COVID-19 patients were separated from other health facilities (25). For example, in Mazandaran province, one of the northern provinces of Iran, from February 24 to May 2, seven hospitals were responsible for admitting pregnant women diagnosed with COVID-19 (26). Psychological interventions for the general public were initially presented as a guideline, and then the guideline was presented to medical teams, including nurses and psychiatrists. In some cases, in addition to these instructions, initial training was provided also to health teams (27). Prenatal care and psychological screening started to be carried out virtually and in-person in a shorter period of time than before. In the case of the presence of COVID-19 symptoms in the pregnant women referring to prenatal clinics, the resident health team present in the hospital would be assisted to perform the necessary psychological interventions until full recovery to maintain mothers’ calm and mental health (25-27).
Because of the great importance of mental health, psychological measures still need to be expanded and completed. It is recommended that the necessary interventions for pregnant women be developed, specifically in two stages: before and after childbirth, both directly (to pregnant women) and indirectly (to families and all active medical staff in hospitals). Because smart facilities (ie, mental health online education and screening services) are not accessible to low-income groups of society, broadcasting educational videos about mental health on the national media, such as radio and television, can also be particularly helpful. Finally, it is suggested that in addition to online psychological screening, all pregnant women be checked during admission to the hospital.
