Risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic: Evidence from meta-analysis

Background The prevalence of anxiety and depression in pregnant women has significantly increased after the spread of COVID-19 throughout the world. We carried out this meta-analysis to reveal the information about risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic. Methods We searched the PubMed, Embase and CNKI (China National Knowledge Infrastructure) databases for all articles. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the risk factors for mental health. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics. Results We collected 17 studies including 15,050 pregnant women during the COVID-19 pandemic. Our results found that factors including decrease in the perception of general support and difficulties in household finances have damage effects on anxiety, and factors including undereducated, unemployed during pregnancy, with a chronic physical illness before pregnancy, decrease in the perception of general support, difficulties in household finances, disobey the isolation rules, and smoking during pregnancy have increased risk of depression. Conclusion Our meta-analysis revealed some risk factors for mental health in pregnant women during COVID-19 pandemic. Mental health interventions in pregnant women may involve targeted methods individually.


Data extraction
Two authors (Yupeng Luo and Kui Zhang) independently reviewed and extracted the data needed. Disagreements were resolved through discussion among the authors to achieve a consensus. The following information was recorded for each study: first author, year of publication, region, risk factors, diagnostic criteria, cases and population (all of the data are shown in Table 1).

Statistical analysis
The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the risk factors for depression and anxiety in pregnant women during the COVID-19  pandemic. The statistical heterogeneity among studies was assessed with the Q-test and I 2 statistics [18]. If there was no obvious heterogeneity, the fixed-effects model (the Mantel-Haenszel method) was used to estimate the summary OR [19]; otherwise, the random-effects model (the DerSimonian and Laird method) was used [20]. Finally, random effects models were used to calculate the overall OR estimates and 95% CIs to assess the risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic. To explore sources of heterogeneity across studies, we did logistic meta-regression analyses. We examined the following study characteristics: publication year, region, number of cases, and number of population. Publication bias was evaluated with funnel plot and Begg's rank correlation method [21]. The statistical analyses were performed by STATA 12.0 software (Stata Corp., College Station, TX).

Quantitative synthesis
For anxiety, factors including age, education, parity, working status during pregnancy, chronic illness, regular physical activity, general support, family annual income, and follow the isolation rules were assessed in pregnant women during the COVID-19 pandemic. Finally, decrease in the perception of general support, smoking during pregnancy and difficulties in household finances have damage effects on anxiety during pregnancy amid the COVID-19 pandemic (OR = 1.10, 95% CI = 1.03-1.17 for decrease in the perception of general support, OR = 3.00,  Table 2 and Fig 2). For depression, factors including age, education, parity, working status during pregnancy, chronic illness, regular physical activity, general support, family annual income, smoking during pregnancy, and follow the isolation rules were assessed in pregnant women during the COVID-19 pandemic. Finally, undereducated, unemployed during pregnancy, with a chronic physical illness before pregnancy, decrease in the perception of general support, difficulties in household finances, disobey the isolation rules, and smoking during pregnancy have increased risk of depression during pregnancy amid the COVID-19 pandemic (OR = 1.41, 95% CI = 1.10-1.81 for undereducated, OR = 1.68, 95% CI = 1.25-2.25 for unemployed during pregnancy, OR = 2.10, 95% CI = 1.13-3.90 for chronic physical illness before pregnancy, OR = 1.06, 95% CI = 1.03-1.10 for decrease in the perception of general support, OR = 1.76, 95% CI = 1.24-2.50 for difficulties in household finances, OR = 1.05, 95% CI = 1.05-1.05 for disobey the isolation rules, and OR = 2.91, 95% CI = 2.04-4.16 for smoking during pregnancy, shown in Table 2 and Fig 3).

Evaluation of heterogeneity
To explore sources of heterogeneity across studies, we did logistic meta-regression analyses. Logistic meta-regression analyses found no possible factors that may substantially influence the initial heterogeneity.

Sensitivity analysis
The influence of a single study on the overall meta-analysis estimate was investigated by omitting one study at a time, and the omission of any study made no significant difference, indicating that our results were statistically reliable.

Publication bias
The Begg's test was performed to evaluate the publication bias of selected literatures. No evidence of publication bias in our study was observed (all P > 0.05).

Discussion
The prevalence of anxiety and depression among pregnant women increased significantly during the COVID-19 epidemic. Our meta-analysis found that facors including decrease in the perception of general support, smoking during pregnancy and difficulties in household finances have damage effects on anxiety during pregnancy, and factors including undereducated, unemployed during pregnancy, with a chronic physical illness before pregnancy, decrease in the perception of general support, difficulties in household finances, disobey the isolation rules, and smoking during pregnancy have increased risk of depression during pregnancy amid the COVID-19 pandemic.
Education is an important factor related to the development of anxiety and depression during pregnancy. Although our results only found higher risk of depression in pregnant women with low education levels, pregnant women with low education levels have been reported to be a high risk of developing both anxiety and depressive symptoms [8,37]. This may be explained by the fact that pregnant mothers with a high level of education had more awareness and were easier to access the correct information of COVID-19 pandemic than low-educated pregnant mothers [8,38], and were better adapted to pandemic conditions [39].
In accordance with previous findings [40,41], the present study revealed that the risk of depression is higher in pregnant women who are not working during the pandemic. Nanjundaswamy et al. [42]found that approximately 35% of pregnant women in India have job related concerns. Being unemployed or being a housewife during the pandemic increases the time spent at home and reduces socialization and interpersonal communication, thereby may increase the risk of anxiety and depression.
Physical activity may play an important role in the management of mild-to-moderate mental health diseases, especially depression and anxiety [43]. WHO 2020 guidelines on physical activity and sedentary behavior [44] provides the recommendation for regular strength training to be included for pregnant women. Previous studies indicated that regular activity during pregnancy can reduce the likelihood of anxiety and depression [11,41]. Our research with limited data failed to confirm the above result.
Chronic illness have been stressed as high risk for complications in severe COVID-19 patients with increased disease severity and mortality [45][46][47], therefore, pregnant women with a history of chronic illness may be more anxious than those without. As a result of psychological distress, pregnant women may choose not to receive antenatal care at health facilities due to worries about being infected with COVID-19 [48]. Our research found increased risk of depression in pregnant women with a chronic physical illness before pregnancy.
Decrease in the perception of general support and difficulties in household finances were important factors associated with both anxiety and depression during pregnancy. lack of social and or partner support and or family care is closely associated with increased risk of prenatal symptoms of anxiety and depression [49,50], prenatal anxiety was related to nobody providing support in everyday life [12]. Prior research has found that lower income and financial struggles are associated with increased risk of poor mental health in pregnancy [51]. During the COVID-19 pandemic these financial stressors have only increased, with record unemployment. Finally, financial stress was significantly associated with the likelihood of having clinically significant anxiety and depression during COVID-19 pandemic.
Self-isolate at home may make the pregnant women feel secure during COVID-19 pandemic, but spending more time with their intimate partners may also increase partner violence, especially emotional abuse, which can lead to unhealthy emotions and even adverse birth outcomes for pregnant women [37]. Previous study have shown that social distancing and isolation at home after the COVID-19 pandemic has greatly impacted human health, causing sudden lifestyle changes with accompanying social and economic consequences [52].
Interestingly, we also found that pregnant women who smoked were at higher risk of depression and anxiety. Recent study suggested that depression appears to be associated with smoking dependence and mediated by neuroticism [53]. Otherwise, attempting to maintain better mood may be a motivating factor for smoking among depressed individuals [54]. Furthermore, pregnancy is a stressful event that alters women's hormonal balance [55], and thus pregnant women might tend to respond to their uncomfortable feelings by smoking and drinking.
A few limitations of our study should be considered. There was heterogeneity among studies although we performed logistic meta-regression analyses and stratified analysis to explore sources of heterogeneity across studies, we still found no possible factors that may substantially influence the initial heterogeneity, and the heterogeneity may potentially affect the results. Moreover, although we did not observe significant publication bias, publication bias is possible in any meta-analysis.
In conclusion, our meta-analysis indicated that education status, unemployed during pregnancy, with a chronic physical illness before pregnancy, general support, household finances, disobey the isolation rules, and smoking during pregnancy were risk factors for mental health in pregnant women during COVID-19 pandemic. Mental health interventions in pregnant women may involve targeted methods individually.

Relevance for clinical practice
The present meta-analysis found that factors including decrease in the perception of general support and difficulties in household finances have damage effects on anxiety, and factors including undereducated, unemployed during pregnancy, with a chronic physical illness before pregnancy, decrease in the perception of general support, difficulties in household finances, disobey the isolation rules, and smoking during pregnancy have increased risk of depression in pregnant women during the COVID-19 pandemic. The prevalence of anxiety and depression in pregnant women has significantly increased after the spread of COVID-19 throughout the world, and that may substantially pose adverse effect on the offspring. Our meta-analysis revealed some risk factors for mental health in pregnant women, and provided advices that mental health interventions in pregnant women during COVID-19 pandemic may involve targeted methods individually.