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.