4 | DISCUSSION
This study has revealed that while the COVID-19 pandemic has elevated
the distress of pregnant women, the increased health-seeking behaviour
(online, professional, and traditional) has reduced their distress due
to “inadequate partner involvement”. Besides, pregnancy distress risk
was found 5.4 times higher in pregnant women who made a change in their
mode of birth preferences due to the pandemic than those who preferred
vaginal mode of birth before and during the pandemic.
It was seen in the study that the “TPDS total score” and “negative
affectivity sub-scale” mean score of the pregnant women were found to
be higher during the COVID-19 pandemic than pre-pandemic, and the mean
distress score caused by ”inadequate partner involvement” decreased
(p<0.001) (Graphic 1). According to the cut-off point of TPDS,
the risky (28 points and above) level of distress of pregnant women
increased 4 times during the pandemic compared to the pre-pandemic
(Table 2). These two findings of the study support each other and
indicate that the pandemic elevates pregnancy distress. TPDS evaluates
the anxiety, stress, and depression of pregnant women. Research has
shown that the levels of anxiety and depression experienced by pregnant
women during the pandemic are significantly higher than before the
pandemic.13,21,31 The results of the study are
consistent with the literature.
In the pandemic, the distress of the pregnant woman varies depending on
factors such as the status of adherence to the COVID-19 regulations, the
state of accessing and benefiting from the information source, the
duration and frequency of lockdown, the socio-demographic, obstetric,
and cultural characteristics of the pregnant women, the week of
gestation, risk status of pregnancy, the quality of antenatal service in
the country, number of children,6,18,32 pregnant
women’s coping methods, social support perception, economic status and
spousal support.5,6,9,25,33 The unprevented/untreated
trauma of the pregnant woman may lead to the deterioration of the mental
health of the pregnant woman and the epigenetic transfer of the trauma
to the next generations.34 Therefore, in the pandemic,
it is necessary for healthcare professionals to evaluate the distress
level of each pregnant and the associating factors and to provide
psychosocial support to those with high distress, and monitor them
afterward.21,24,25,33
In this study, TPDS “distress due to inadequate partner involvement”
sub-scale score was found lower during the pandemic than pre-pandemic
period. It is believed that due to the national policies against ongoing
pandemic, the pregnant women’s partners “working home office” and
“flexible working hours” made it possible for couples to “spend more
time together at home” and since more than “half of the pregnant women
in the study are nulliparous, they do not have to take care of another
child at home”, which may have contributed to the “reduction of
distress” caused by inadequate partner involvement and “positive
partner relationship”. Evidence suggests that unlike women who have
financial difficulties, whose husbands have been laid off during the
pandemic process or who have many children,35,36partner relationships of those without financial and domestic problems
have been positively affected,7,18,37 noted that
pregnant women with poor partner support in the COVID-19 pandemic
experienced more anxiety and depression symptoms.
Situations that alarming the society, such as pandemics and disasters,
may increase the pregnant woman’s desire to be informed about her own
and foetus health and the need for professional support, as they cause
more distress in the pregnant woman.8,11,33 In this
study, some pregnant women expressed that they wanted to be “informed”
about the impacts of COVID-19 on the health of pregnant (59.54%) and
foetus (67.81%), that they found the source of information
“insufficient” and “needed the support of health professionals
(40%)”. This finding of the study reveals the unmet “education and
care needs and expectations” of pregnant women during the pandemic
period. Similarly, in some studies, pregnant women found the counselling
of healthcare professionals insufficient about COVID
19,11 they were not sufficiently
informed,5 so felt neglected by health professionals,
and wanted to be given information.8
During the pandemic, the concerns of the pregnant about
pregnancy-birth-breastfeeding, difficulties in accessing
antenatal-innatal-postnatal services can increase the health-seeking
behaviour of the pregnant woman.15,18,31,38 In this
study, the health-seeking behaviour of pregnant women in the pandemic
was evaluated considering the maximum values of the scale, and it was
concluded that pregnant women have above the average “health-seeking
behaviour” with the following scores; 42.86±7.39 (max:60) from the
total score of HSBS, 19.58±5.25 (max:30) from the online health-seeking
subscale, 13.51±1.85 (max:15) from professional health-seeking subscale
and 9.77±2.61 (max:15) from traditional health-seeking subscale. A
relevant study suggested that the health-seeking behaviour (especially
online) in the obstetrics of pregnant women in the second and third
trimesters during the pandemic increased.39 The reason
for the pregnant women in this study to have more health-seeking
behaviours towards birth and the baby may be because most of them are in
the third trimester and their due date approaches. The fact that the
traditional health-seeking behaviour of pregnant women is lower than the
others suggests that pregnant women may receive more online and
professional support and may have remained away from traditional
health-seeking behaviours such as ”friend support” due to social
isolation. It should be kept in mind that exposure of pregnant women to
unconfirmed and distorted information about birth may cause them more
distress by creating fear.
In the study, it was determined that the increase in health-seeking
behaviour (online, professional, and traditional) in pregnant women
during the pandemic reduced the distress of pregnant due to inadequate
partner involvement (p<0.001) (Table 3). This finding of the
study suggests that the increase in health-seeking behaviour in pregnant
women may have contributed to the reduction of the distress that would
occur as a result of inadequate partner involvement by meeting the needs
of pregnant women for the COVID-19 period and pregnancy. In addition,
this finding shows that during the lockdown, pregnant women may engage
in health-seeking behaviour at home with their partners, which may
influence reducing their anxiety. Meeting the information needs of the
pregnant woman reduces her distress.18,35Parra‐Saavedra et al. (2020)26 observed more anxiety,
depression, and fear in pregnant women who were insufficiently informed
about COVID 19 than those who were well informed. The first three
sources of information in the study were found to be the obstetrician
(44.44%), family physician (24.22%), and midwife (20.51%) (Table 2).
This finding of our study overlaps with the finding that pregnant women
have a mean score of 13 for “professional health-seeking behaviour”,
which is close to the maximum value 15. This finding indicates that
pregnant women see healthcare professionals as their primary source of
information during the pandemic. Research has indicated that those with
high professional health-seeking behaviour had lower online
health-seeking behaviour.40 In the study, two out of
every three pregnant women (69.52%) stated that they benefited from an
“online” resource for the COVID-19 outbreak. Similarly, the literature
reports that pregnant women have an increased rate of access to
information, online, e-health, m-health health-seeking behaviour due to
social distance rules.26,39 An important point to
consider is that pregnant women may also be in the behaviour of seeking
professional health care to interpret and discuss the information they
obtain online.13
The pandemic can lead to an increase in anxiety about childbirth and
health-seeking behaviour of pregnant women.8,9,11 In
this study, more than half of the pregnant women (54.99%) stated that
giving birth during the pandemic would create difficulties for them
(Table 2), and they would like to be informed about which mode of birth
(vaginal/caesarean section) is beneficial for the health of the
“foetus/new-born” (%24.7) and “pregnant women” (33%) (Table 2). Wu
et al. (2020) explained that some pregnant women wanted to be informed
about birth by health professionals and they preferred home birthing due
to fear of virus transmission. In this study, 11.3% of the pregnant had
a change in their preference of a mode of birth due to pandemic (from
vaginal to caesarean or from caesarean to vaginal), and 12% of them
have not yet decided on the mode of birth. In the study by Yassa et al.
(2020) in which they examined the birth mode preferences of pregnant
women in the COVID-19 pandemic, it was seen that 55.2% did not have a
change in their preference, 18% of them thought to change, 26.7% “did
not decide yet”. In Yassa et al. (2020)11 ’s study,
the reason why the thought of changing the birth mode and the indecisive
percentage of pregnant women is different from our study may be that the
study was conducted when the pandemic was first declared in the world,
and there were more uncertainties and concerns about the virus in
pregnant women in that period. For pregnant women have not decided on
the mode of birth yet, their are and counselling needs should be met,
distress should be eliminated, and they supported to make autonomic and
conscious decisions about the mode of birth.33
If the distress of the pregnant woman cannot be eliminated/prevented in
the ongoing pandemic, the birth self-efficacy of the pregnant woman
decreases,5,41 the mode of birth and the place of
birth preference may change.8,10 In our study, the
pregnant women who had a change in the mode of birth preference (from
vaginal birth to caesarean or from caesarean to vaginal birth)” before
and during the COVID-19 pandemic, had a 5.4 times higher risk of
gestational distress than those who preferred only vaginal birth before
and during the epidemic (p<0.05) (Table 4).
The fact that most of the pregnant women in this study were nulliparous
in their third trimester may also increase the risk of distress and
anxiety about the mode of birth in the pandemic. Moreover, the fact that
more than half of the pregnant women prefer vaginal birth (53.3%) and
are nulliparous (54.1%), one out of five pregnant women benefit from
the midwife as a source of information reveals the importance of
antenatal midwifery care services for women to maintain and realize
their mode of birth preferences. In Turkey, Cesarean- Section (CS) rate
is very high (52%) (TNSA, 2018). Midwives should maintain the
midwife-woman relationship and antenatal services (online, tele
counselling, etc.), provide the pregnant women with information about
pregnancy and child birthing, and promote their self-efficacy and
decision-making skills for childbirth.5,25,41 It is
predicted that all these regulations can substantially contribute to the
promotion of quality of antenatal care recommended by WHO during the
pandemic period and thus increase the positive pregnancy and childbirth
experience.