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Prenatal stress, health, and health behaviours during the COVID-19 pandemic: An international survey

Open AccessPublished:March 18, 2021DOI:https://doi.org/10.1016/j.wombi.2021.03.007

      Abstract

      Background

      Pregnant women’s stress, mental and physical health, and health behaviours can have important implications for maternal and child health outcomes.

      Aim

      To examine pregnant women’s levels of stress, mental and physical health, and health behaviours during the COVID-19 pandemic.

      Methods

      A cross-sectional survey was conducted online, with recruitment and data collection occurring between 16/6/20 and 17/7/20. Participants were pregnant women recruited via online pregnancy/parenting communities. Participants self-reported their levels of general stress, pregnancy-specific stress and COVID-19 related stress, mental and physical health, general health behaviours, and COVID-19 related health behaviours.

      Findings

      573 pregnant women participated in the survey. Participants were most commonly resident in the United States (42.6%, n = 243), Ireland (41.2%, n = 235) or the United Kingdom (10%, n = 57). The majority (80.0%, n = 457) were married and educated to degree level or above (79.3, n = 453). Pregnant women reported high levels of pregnancy-specific and COVID-19-related stress, and low levels of mental and physical health, during the pandemic. Encouragingly, pregnant women in this study generally reported high levels of adherence to public health advice and pregnancy health behaviours. Stress and general mental health outcomes were best predicted by well-being factors (including stress and social support). Health impairing behaviours (e.g. poor diet) were predicted by both well-being and demographic factors.

      Discussion

      Interventions targeting pregnancy- and pandemic-specific stress at the population level will be essential to support mental health and minimise adverse outcomes for women and children during the pandemic.

      Keywords

      Statement of significance

      Problem

      The COVID-19 pandemic may increase prenatal stress and, in turn, adversely impact both health behaviours and health outcomes.

      What is already known

      The pandemic has been associated with increased incidence of mental health symptoms in general and pregnant populations, and poses a threat to protective factors like social support.

      What this paper adds

      A multidimensional examination of prenatal general, pregnancy-specific, and COVID-19 related stress, health, and health behaviours during the COVID-19 pandemic. The study found high adherence to both pregnancy- and pandemic-related health advice. Evidence of high levels of pregnancy- and pandemic-related stress provide insight into potentially useful targets for stress intervention.

      Introduction

      Many women experience disruptions to mental health during pregnancy. It is estimated, for example, that between 7% and 30% of women exhibit symptoms of depression during their pregnancies [
      • Biaggi A.
      • Conroy S.
      • Pawlby S.
      • Pariante C.M.
      Identifying the women at risk of antenatal anxiety and depression: a systematic review.
      ]; between 18.2% and 24.6% report anxiety [
      • Dennis C.
      • Falah-Hassani K.
      • Shiri R.
      Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis.
      ]; and up to 84% experience stress [
      • Woods S.M.
      • Melville J.L.
      • Guo Y.
      • Fan M.Y.
      • Gavin A.
      Psychosocial stress during pregnancy.
      ]. Depression, stress and anxiety are related yet distinct psychological constructs [
      • Eysenck M.W.
      • Fajkowska M.
      Anxiety and depression: toward overlapping and distinctive features.
      ,
      • Glover V.
      Prenatal stress and the origins of psychopathology: an evolutionary perspective.
      ] which have been associated with a range of poor outcomes including increased risk of premature birth and reduced length of gestation [
      • Voellmin A.
      • Etringer S.
      • Moog N.
      • Wadhwa P.D.
      • Buss C.
      Maternal positive affect over the course of pregnancy is associated with the length of gestation and reduced risk of preterm delivery.
      ] and disruptions to hormonal regulation in children [
      • de Bruijn A.T.
      • van Bakel H.J.
      • Wijnen H.
      • Pop V.J.
      • van Baar A.L.
      Prenatal maternal emotional complaints are associated with cortisol responses in toddler and preschool aged girls.
      ]. Prenatal mental health issues may also be associated with poorer physical health and health behaviours, with further direct and indirect effects on maternal and infant outcomes [
      • Lobel M.
      • Cannella D.L.
      • Graham J.E.
      • DeVincent C.
      • Schneider J.
      • Meyer B.A.
      Pregnancy-specific stress, prenatal health behaviors, and birth outcomes.
      ]. For instance, low physical activity, poor diet, and substance use during pregnancy are associated with increased risk of adverse prenatal [
      • Bailey B.A.
      • Sokol R.J.
      Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome.
      ], health [
      • Bailey B.A.
      • Sokol R.J.
      Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome.
      ,
      • Castles A.
      • Adams E.K.
      • Melvin C.L.
      • Kelsch C.
      • Boulton M.L.
      Effects of smoking during pregnancy. Five meta-analyses.
      ,
      • Davenport M.H.
      • Ruchat S.
      • Poitras V.J.
      • Garcia A.J.
      • Gray C.E.
      • Barrowman N.
      Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis.
      ,
      • Pineles B.L.
      • Hsu S.
      • Park E.
      • Samet J.
      Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy.
      ], and child developmental [
      • Malin A.J.
      • Busgang S.A.
      • Cantoral A.J.
      • Svensson K.
      • Orjuela M.A.
      • Pantic I.
      • Schnaas L.
      • et al.
      Quality of prenatal and childhood diet predicts neurodevelopmental outcomes among children in Mexico city.
      ] outcomes.
      Prenatal stress and mental health issues can arise from multiple factors, including from experiencing stressful life events like the COVID-19 pandemic [
      • King S.
      • Laplante D.
      Using natural disasters to study prenatal maternal stress in humans.
      ,
      • Matvienko-Sikar K.
      • Meedya S.
      • Ravaldi C.
      Perinatal mental health during the COVID-19 pandemic.
      ]. COVID-19, which was declared a pandemic by the World Health Organisation in March 2020 [

      World Health Organisation. Coronavirus Disease 2019 (COVID-19) Situation Report – 51. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10 (11 March 2020, cited 11 December 2020).

      ], is a significant global public health crisis. The pandemic and pandemic-related restrictions, such as lock-downs and quarantining, are already demonstrating significant negative effects for psychological well-being [
      • Torales J.
      • O’Higgins M.
      • Castaldelli-Maia J.M.
      • Ventriglio A.
      The outbreak of COVID-19 coronavirus and its impact on global mental health.
      ]. In frontline workers and general populations, COVID-19 has been associated with increased risks for depression, anxiety [
      • Torales J.
      • O’Higgins M.
      • Castaldelli-Maia J.M.
      • Ventriglio A.
      The outbreak of COVID-19 coronavirus and its impact on global mental health.
      ,
      • Czeisler M.E.
      • Lane R.I.
      • Petrosky E.
      • Wiley J.F.
      • Christensen A.
      • Njai R.
      Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020.
      ,
      • Rajkumar R.P.
      COVID-19 and mental health: a review of the existing literature.
      ] vicarious trauma, and sleep disruptions [
      • Torales J.
      • O’Higgins M.
      • Castaldelli-Maia J.M.
      • Ventriglio A.
      The outbreak of COVID-19 coronavirus and its impact on global mental health.
      ,
      • Rajkumar R.P.
      COVID-19 and mental health: a review of the existing literature.
      ]. High rates of substance use and suicidal ideation have also been reported among a general population during the pandemic [
      • Torales J.
      • O’Higgins M.
      • Castaldelli-Maia J.M.
      • Ventriglio A.
      The outbreak of COVID-19 coronavirus and its impact on global mental health.
      ].
      Pregnant women are potentially at increased risk of adverse outcomes during the pandemic due to compounding pregnancy-specific concerns. For example, women may experience distress due to fear of coronavirus infection during pregnancy and/or in fetuses and children [
      • Corbett G.A.
      • Milne S.J.
      • Hehir M.P.
      • Lindow S.W.
      • O’Connell M.P.
      Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic.
      ]; lack of clarity about pregnancy-specific risks of COVID-19 and which precautions are most effective at reducing infection risks to infants [
      • Yassa M.
      • Birol P.
      • Yirmibes C.
      • Usta C.
      • Haydar A.
      • Yassa A.
      • et al.
      Near-term pregnant women’s attitude toward, concern about and knowledge of the COVID-19 pandemic.
      ]; and changes to maternity services and birth plans due to public health restrictions [
      • Corbett G.A.
      • Milne S.J.
      • Hehir M.P.
      • Lindow S.W.
      • O’Connell M.P.
      Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic.
      ,
      • Yassa M.
      • Birol P.
      • Yirmibes C.
      • Usta C.
      • Haydar A.
      • Yassa A.
      • et al.
      Near-term pregnant women’s attitude toward, concern about and knowledge of the COVID-19 pandemic.
      ]. In addition, COVID-19 restrictions have placed significant limitations on women’s levels and types of social support, which has the potential to further strain their coping resources [
      • Corbett G.A.
      • Milne S.J.
      • Hehir M.P.
      • Lindow S.W.
      • O’Connell M.P.
      Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic.
      ,
      • Thapa S.S.B.
      • Mainali A.
      • Schwank S.E.
      • Acharya G.
      Maternal mental health in the time of the COVID-19 pandemic.
      ]. Given the proposed stress-buffering effects of social support, this may also increase women’s risk of adverse outcomes both during pregnancy and beyond [
      • Cohen S.
      • Wills T.A.
      Stress, social support, and the buffering hypothesis.
      ].
      To date, some negative outcomes of the COVID-19 pandemic have been demonstrated in pregnant populations. For instance, one Canadian study reported increased incidences of anxiety, depression, post-traumatic stress, and dissociative symptoms among women pregnant during the COVID-19 pandemic, compared to a pre-pandemic cohort [
      • Berthelot N.
      • Lemieux R.
      • Garon-Bissonnette J.
      • Drouin-Maziade C.
      • Martel É
      • Maziade M.
      Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic.
      ]. Another study reported increased levels of depressive symptoms in pregnant women in China after COVID-19 was declared an epidemic there in late January, again compared to a pre-pandemic baseline in the same population [
      • Wu Y.
      • Zhang C.
      • Liu H.
      • Duan C.
      • Li C.
      • Fan J.
      • et al.
      Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China.
      ]. Reduced perceived social support has also been found among women pregnant in Ireland during the pandemic [
      • Matvienko-Sikar K.
      • Pope J.
      • Cremin A.
      • Carr H.
      • Leitao S.
      • Colander E.K.
      • Meaney S.
      Differences in levels of stress, social support, health behaviours, and stress-reduction strategies for women pregnant before and during the COVID-19 pandemic, and based on phases of pandemic restrictions, in Ireland.
      ], and women also self-reported lower physical activity, compared to those pregnant before the pandemic [
      • Davenport M.H.
      • Meyer S.
      • Mesh V.L.
      • Strynadka M.C.
      • Khurana R.
      Moms are not OK: COVID-19 and maternal mental health.
      ]. These early findings suggest that women pregnant during the pandemic may be at risk for impaired prenatal psychological well-being and health behaviours. Examinations of stress have been limited however, with studies tending to focus on depression and/or anxiety symptoms. Similarly there has been little to no examination of prenatal health behaviours. Given the importance of maternal mental health, stress and health behaviours for maternal and child outcomes, examining these factors during the COVID-19 pandemic is essential to inform approaches to supporting pregnant women during this, and potential future, pandemics. The aim of this study is to examine pregnant women’s levels of stress, mental and physical health, and health behaviours during the COVID-19 pandemic.

      Participants, ethics and methods

      Design

      A cross-sectional online survey of pregnant women was conducted. This study forms part of a larger project examining prenatal stress, social support and health behaviours [

      K. Matvienko-Sikar, J. Pope, S. Leitao, E.K. Colander, S. Meaney. Prenatal Well-being and Health Behaviours. Available from: https://doi.org/10.17605/OSF.IO/X357B (2020 August 23; cited 11 December 2020).

      ].

      Ethical considerations

      Ethical approval was granted by the [redacted] Research Ethics Committee and the Clinical Research Ethics Committee at [redacted]. Funding organisations were not involved in conceptualising the study, collecting data, analysing/reporting results, or any decisions related to publication.

      Participants

      Participants in this study were pregnant women over 18 years of age. No exclusions were made based on nationality or current place of residence. Participants were recruited between June 16th, 2020 and July 17th, 2020. All participants were recruited online via public postings on forums associated with pregnancy websites (e.g What To Expect, Mumsnet), and on social media pregnancy/parenting communities (e.g. Facebook, Twitter, Instagram, Reddit); a full list of targeted communities is available in Supplement 1. Participants were provided with a brief study description and link to the study survey, containing the full study information leaflet and consent form. Participants provided consent prior to completing the survey.

      Measures

      The survey included open and closed questions on demographic factors, stress, mental and physical health, health behaviours, social support, and perceived satisfaction and quality of antenatal care.
      Details and findings in relation to social support, quality of antenatal care, stress-reduction strategies, and experiences of distress during the pandemic are presented in our complementary paper [
      • Meaney S.
      • Pope J.
      • Leitao S.
      • Colander E.K.
      • Matvienko-Sikar K.
      Formal and informal supports for pregnant women during the pandemic: Social support and satisfaction with maternity services.
      ]. As such they are not reported as outcomes in the current paper but are presented here for completeness.

      Demographic factors

      Data on the following demographic factors were collected: age, marital status, education, household income, ethnicity, nationality, country of residence, weeks of pregnancy, and number of previous pregnancies.

      General stress

      General stress was measured using the 4-item Perceived Stress Scale Short Form (PSS-4) [
      • Cohen S.
      • Kamarck T.
      • Mermelstein R.
      A global measure of perceived stress.
      ]. This validated scale asks participants to report frequency of experiencing stress on a 5-point Likert scale ranging from 0 = “never” to 4 = “very often”. Items include “How often have you felt that you were unable to control the important things in your life?” In the current study the PSS-4 had a reliability coefficient of α = .75.

      Pregnancy-specific stress

      Pregnancy-specific stress was measured using the validated 17-item Revised Prenatal Distress Scale (NuPDQ) [
      • Ibrahim S.
      • Lobel M.
      Conceptualization, measurement, and effects of pregnancy-specific stress: review of research using the original and revised prenatal distress questionnaire.
      ]. Items ask participants to report whether they are feeling “bothered, upset, or worried at this point in their pregnancies” about pregnancy-specific issues such as concerns about their pregnancy or baby, and changes to self-image and social relationships. Items are rated on a 3-point Likert scale ranging from 0 = “not at all” to 2 = “very much.” In this study the NuPDQ had a reliability coefficient of α = .76.

      COVID-19 related stress

      At the time of this study there was no published validated scale available to measure COVID-19 related stress during pregnancy. As such, and guided by available evidence from a recent study by Zhong et al. [
      • Zhong B.-L.
      • Luo W.
      • Li H.-M.
      • Zhang Q.-Q.
      • Liu X.-G.
      • Li W.-T.
      • et al.
      Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey.
      ], 6 items were developed to examine women’s concerns about the COVID-19 pandemic in this study. Participants were asked to indicate how worried they were about the coronavirus overall using a single item, and 5 items assessing concerns about coronavirus infection, being able to sleep because of coronavirus concerns, restrictions in place due to the coronavirus, and access to antenatal care due to the coronavirus. Items were measured using a 3-point Likert scale ranging from 0 = “not at all” to 2 = “very much.” The internal validity for this measure was α = .77.

      Mental and physical health

      Mental and physical health were measured using the mental and physical domains of the validated 12-item Short Form Survey (SF-12) [
      • Ware J.
      • Kosinski M.
      • Keller S.D.
      A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity.
      ]. Participants indicated their general perceived health on a 5-point Likert scale (ranging from 1 = “excellent” to 5 = “poor”). Participants were also asked to indicate health-related limitations to activities using a 3-point Likert scale (ranging from 1 = “Limited a lot” to 3 = “Not at all limited”), and by answering “yes” or “no” to questions about specific limitations. Participants indicated how much pain was interfering with their ability to work using a five-point Likert scale (ranging from 1 = “not at all” to 5 = “extremely”). Participants were also asked about the frequency of emotional experiences, such as “feeling down-hearted or blue” and whether their health interfered with social functioning, on a 6-point Likert scale (ranging from 1 = “all of the time" to 6 = ”none of the time").

      Prenatal health behaviours

      Frequency of engaging in prenatal health behaviours was measured using the validated 20-item Prenatal Health Behaviour (PHBS) scale [
      • Auerbach M.V.
      • Nicoloro-SantaBarbara J.
      • Rosenthal L.
      • Kocis C.
      • Weglarz E.R.
      • Busso C.
      • et al.
      Psychometric properties of the prenatal health behavior scale in mid- and late pregnancy.
      ]. Health behaviours were grouped into a health-promoting behaviours subscale (α = .72) and a health-impairing behaviours subscale (α = .55) as per previous guidance [
      • Auerbach M.V.
      • Lobel M.
      • Cannella D.T.
      Psychosocial correlates of health-promoting and health-impairing behaviors in pregnancy.
      ]. Health-promoting behaviours included exercise, stretching, getting enough sleep, taking vitamins, and maintaining a good diet. Health-impairing behaviours included skipping meals, consuming snack foods instead of balanced meals, consuming drinks with caffeine, and smoking cigarettes. Items are measured on a Likert scale ranging from 0 = "never" to 4 = "very often". The internal consistency of the health-promoting subscale was α = .72. The internal consistency of the health-impairing subscale was α = .55, which, though lower than desired, is in keeping with previous examinations [
      • Auerbach M.V.
      • Nicoloro-SantaBarbara J.
      • Rosenthal L.
      • Kocis C.
      • Weglarz E.R.
      • Busso C.
      • et al.
      Psychometric properties of the prenatal health behavior scale in mid- and late pregnancy.
      ].

      COVID-19 related health behaviours

      Six items were developed to assess women’s adherence to COVID-19 related health behaviours. Women were asked to report whether they were using a mask outside the home and in hospital, avoiding crowded places, leaving the house only when essential, shaking hands or making close contact with people, and disinfecting frequently touched objects, by answering either “yes” or “no.”

      Social support

      Social support was measured using the 12-item Multidimensional Perceived Social Support Scale (MSPSS) [
      • Zimet G.D.
      • Dahlem N.W.
      • Zimet S.G.
      • Farley G.K.
      The multidimensional scale of perceived social support.
      ]. This validated scale asks women rated their perceived degree of support from significant others, family and friends, by rating statements (for example: “There is a special person with whom I can share my joys and sorrows”) on a 7-point Likert scale ranging from 1 = "very strongly disagree" to 7 = "very strongly agree." The overall scale reliability was α = .96; the reliability of the significant other, family, and friends subscales were α = .98, α = .94, and α = .96 respectively.

      Open-ended questions

      Women were also invited to provide additional qualitative feedback on their prenatal stress experiences including what they found stressful, what stress-reduction strategies they engaged in, and what services and supports they use/want/need during their pregnancies.

      Analysis

      Descriptive statistics were used to summarise information on participant demographics, stress, mental and physical health, social support, health behaviours, and COVID-19 related behaviours. Associations between demographic factors, stress, mental and physical health, social support, and all health behaviours were examined using Spearman’s rank order correlations. Hierarchical multiple regressions were conducted to examine the role of sociodemographic and well-being factors (stress, mental and physical health, and social support) in predicting general stress, pregnancy-specific stress, COVID-19 related stress, mental and physical health, and health behaviours. Sociodemographic factors were entered at Step 1 of the hierarchical regressions; followed by well-being factors at Step 2 to determine the impact of well-being factors when controlling for sociodemographic factors. Dummy variables were created from multilevel categorical variables for inclusion in the regression models. Chi square tests of independence were conducted to examine potential demographic differences in COVID-19 related health behaviours. Due to the use of multiple inferential tests, Bonferroni corrections were applied with a more stringent significance value, calculated by dividing an alpha of .05 by the number of regression tests (n = 7), which results in a significance value rounded up to p < .01. This more stringent significance value was used in all analyses.

      Results

      573 pregnant women took part in the survey. Participants were most commonly resident in the United States (42.6%, n = 243), Ireland (41.2%, n = 235), or the United Kingdom (10%, n = 57). The majority of participants were married (80%, n = 457) and educated to degree level or above (79.3%, n = 453). The majority (57.2%, n = 325) had been pregnant before. See Table 1 for complete participant characteristics.
      Table 1Participant characteristics.
      M(SD)Range
      Age (years)32.38 (4.6)19−43
      No. weeks pregnant26.22 (9.43)4−42
      No. children.78 (.993)0−7
      n%
      Nationality
       American22039.2
       Other539.9
       British6010.7
       Canadian132.3
       Irish21538.3
      Current country of residence
       America24342.6
       Australia4.7
       Bahrain1.2
       Canada152.6
       Ireland23541.2
       United Kingdom5710.0
       Germany2.4
       Guam1.2
       New Zealand2.4
       Northern Ireland3.5
       Norway1.2
       Scotland1.2
       South Africa2.4
       Spain1.2
       Wales2.4
      Ethnic/cultural background
       Irish22439.2
       Irish Traveller1.2
       Other white background28950.5
       African61.0
       Other Black background3.5
       Other Asian background71.2
       Hispanic/Latina132.3
       Mixed Ethnicity132.3
       Other101.7
       Not stated61.0
      Highest level of education
       Secondary school264.6
       Technical/vocational qualification396.8
       Non-degree qualification539.3
       Undergraduate degree21337.3
       Postgraduate degree19734.5
       Doctorate437.5
      Relationship status
       Married45780.0
       Cohabiting7613.3
       In a relationship295.1
       Single91.6
      First pregnancy
       No32557.2
       Yes24342.8
      Prior pregnancy loss
       Never36563.7
       Yes, once14124.6
       Yes, twice396.8
       Yes, 3 or more times284.9
      Details of women’s self-reported general stress, pregnancy-specific stress, COVID-19 related stress, and perceived mental and physical health are presented in Table 2. For COVID-19 related stress, 58% of participants reported feeling “very” concerned about COVID-19 related restrictions; 39.4% of women reported feeling “very” concerned about their babies becoming unwell because of the coronavirus; and only 31.7% of participants felt confident that COVID-19 would be successfully controlled. Participants reported normative levels [
      • Wartting S.L.
      • Forshaw M.J.
      • South J.
      • White A.K.
      New, normative, English-sample data for the short form perceived stress scale (PSS-4).
      ] of general stress (M = 6.54, SD = 2.84), and high [
      • Ibrahim S.
      • Lobel M.
      Conceptualization, measurement, and effects of pregnancy-specific stress: review of research using the original and revised prenatal distress questionnaire.
      ] levels pregnancy-specific stress (M = 13.89, SD = 5.37). Participants also reported low levels of physical (M = 44.3, SD = 9.2) and mental health (M = 42.5,SD = 11.3) [
      • Gandek B.
      • Ware J.E.
      • Aaronson N.K.
      • Apolone G.
      • Bjorner J.B.
      • Brazier J.E.
      • Bullinger M.
      • Kaasa S.
      • Leplege A.
      • Prieto L.
      • Sullivan M.
      Cross-validation of item selection and scoring for the SF-12 health survey in nine countries: results from the IQOLA project.
      ].
      Table 2Participant stress, mental and physical health, and social support.
      M(SD)Range
      General stress (PSS)6.54 (2.84).00−15.00
      Pregnancy-specific stress (PDQ)13.89 (5.37).00−30.00
      COVID-related stress7.14 (2.84).00−12.00
      SF-12 Mental Health Component42.49 (11.30)10.44−65.55
      SF-12 Physical Health Component44.25 (9.17)14.19−64.27
      Perceived Social Support (total) (MSPSS)67.61 (15.89)12.00−84.00
       From significant other24.84 (5.65)4.00−28.00
       From family21.93 (6.21)4.00−28.00
       From friends20.79 (6.42)4.00−28.00
      n%
      Unable to fall or stay asleep due to thinking about the coronavirus
       Not at all26446.2
       Somewhat21337.3
       Very much9416.5
      Worried about being infected by the coronavirus
       Not at all11119.4
       Somewhat26045.5
       Very much20035.0
      Worried about baby becoming unwell because of the coronavirus
       Not at all8915.5
       Somewhat25845.0
       Very much22639.4
      Worried about restrictions in place due to the coronavirus (e.g. social distancing, travel restrictions)
       Not at all468.0
       Somewhat19433.9
       Very much33258.0
      Worried about access to antenatal care because of the coronavirus
       Not at all13323.4
       Somewhat20636.2
       Very much23040.4
      Overall, worry about the coronavirus
       Not at all305.3
       Somewhat28349.7
       Very much25645.0
      Belief that COVID-19 will be successfully controlled
       No13223.1
       Yes18131.7
       I don’t know25845.2
      MSPSS = Multidimensional Scale of Perceived Social Support PSS = Perceived Stress Scale PDQ = Prenatal Distress Questionnaire SF-12 = SF-12® Health Survey.
      Participants reported high frequency of engagement in health-promoting behaviours and low engagement in health-impairing behaviours. For example, most participants reported abstaining entirely from alcohol (87.2%) and cigarettes (96.2%); as such these variables were excluded from further analyses. Participants also reported high levels of adherence to COVID-19 public health advice; for instance, 95.6% of participants reported that they had stopped shaking hands or making close contact with others, while 76.3% reported wearing masks when leaving home (see Table 3).
      Table 3General and COVID-19 Specific Health Behaviors.
      M (SD)Range
      Health-promoting behaviors (PHBS)24.91 (4.33)10.00−32.00
      Health-impairing behaviors (PHBS)10.22 (3.75).00−26.00
      n%
      Frequency of drinking alcohol
      Frequency of prenatal health behaviours is for the preceding month.
       Never49987.2
       Almost never539.3
       Sometimes173.0
       Fairly often2.3
       Very often1.2
      Frequency of smoking cigarettes
      Frequency of prenatal health behaviours is for the preceding month.
       Never55196.2
       Almost never101.7
       Sometimes61.0
       Fairly often2.3
       Very often4.7
      Frequency of exercising for at least 15 min
      Frequency of prenatal health behaviours is for the preceding month.
       Never396.8
       Almost never7913.8
       Sometimes17129.8
       Fairly often14926.0
       Very often13523.6
      Frequency of getting enough sleep
      Frequency of prenatal health behaviours is for the preceding month.
       Never101.8
       Almost never8414.7
       Sometimes18031.6
       Fairly often19834.7
       Very often9817.2
      Going to any crowded place
       No44177.0
       Yes13223.0
      Wearing a mask when leaving home
       No13623.7
       Yes43776.3
      Wearing a mask when in hospital/maternity service
       No7813.6
       Yes49486.4
      Cleaning and disinfecting frequently touched objects/surfaces
       No9817.1
       Yes47582.9
      Leaving the house only when absolutely essential
       No15226.6
       Yes42073.4
      Shaking hands or making close contact with other people
       No244.2
       Yes54895.8
      PHBS = Prenatal Health Behavior Scale.
      a Frequency of prenatal health behaviours is for the preceding month.
      Findings of associations between stress, mental and physical health, and health behaviours using Spearman’s correlations are presented in Supplement 2.

      Predictors of stress, mental and physical health, and health behaviours

      Hierarchical multiple regressions were conducted to examine the role of sociodemographic and well-being factors in predicting stress, mental and physical health, and health behaviours. Preliminary analyses confirmed normality, linearity, multicollinearity and homoscedasticity. A summary of regression outcomes is provided in Table 4 below; full details of each regression are available in Supplements 3–5.
      Table 4Summary of regression outcomes (full details in Supplementary files 3–5).
      RR2ΔR2p Values
      Covid-19 related stress
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .22.05.05.14
      Step 2
      Variables entered at Step 2: Stress measures, Mental and physical health measures, social support.
      .59.31.26<.005
      Pregnancy-specific stress (PDQ)
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .27.08.08.004
      Step 2
      Variables entered at Step 2: Stress measures, Mental and physical health measures, social support.
      .63.39.32<.005
      General stress (PSS)
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .29.08.08.16
      Step 2
      Variables entered at Step 2: Stress measures, Mental and physical health measures, social support.
      .72.51.43.03
      Mental health (SF-12 mental component)
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .34.11.11<.005
      Step 2
      Variables entered at Step 2: Stress measures, health measures, social support PSS=Perceived Stress Scale PDQ=Prenatal Distress Questionnaire SF-12=SF-12® Health Survey.
      .74.54.43<.005
      Physical health (SF-12 physical component)
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .33.11.11<.005
      Step 2
      Variables entered at Step 2: Stress measures, health measures, social support PSS=Perceived Stress Scale PDQ=Prenatal Distress Questionnaire SF-12=SF-12® Health Survey.
      .48.23.12<.005
      Health promoting behaviours
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .32.10.10<.005
      Step 2
      Variables entered at Step 2: Stress measures, health measures, social support PSS=Perceived Stress Scale PDQ=Prenatal Distress Questionnaire SF-12=SF-12® Health Survey.
      .49.25.15<.005
      Health impairing behaviours
      Step 1
      Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      .35.12.12<.005
      Step 2
      Variables entered at Step 2: Stress measures, health measures, social support PSS=Perceived Stress Scale PDQ=Prenatal Distress Questionnaire SF-12=SF-12® Health Survey.
      .41.17.05<.005
      a Variables entered at Step 1: age, parity, gestational age, country of residence, relationship status, education, previous pregnancy loss.
      b Variables entered at Step 2: Stress measures, Mental and physical health measures, social support.
      c Variables entered at Step 2: Stress measures, health measures, social support PSS = Perceived Stress Scale PDQ = Prenatal Distress Questionnaire SF-12 = SF-12® Health Survey.

      COVID-19 related stress

      Sociodemographic factors were entered at Step 1 and explained 4.9% of the variance in perceived stress. After entry of the well-being factors (general stress, pregnancy-specific stress, social support, and mental and physical health) at Step 2, the total variance explained by the model was 31.1%, F (23, 474) = 9.31, p < .001. The well-being factors explained an additional 26.2% of the variance in stress after controlling for sociodemographic factors; R squared change = .26, F change (5, 474) = 36.07, p < .001. In the final model, only general stress (beta = –.41, p < .001) and pregnancy-specific stress (beta = .17, p = .002) predicted COVID-19 related stress. See Supplement 3.

      Pregnancy-specific stress

      Sociodemographic factors entered at Step 1 explained 7.5% of the variance in pregnancy-specific stress. After entry of the COVID-19 related stress, general stress, social support, and mental and physical health at Step 2, the total variance explained by the model was 39.4%, F (23, 474) = 13.42, p < .001. The well-being factors explained an additional 32% of the variance in stress, after controlling for sociodemographic factors; R squared change = .32, F change (5, 474) = 50.07, p < .001. In the final model, the number of children women had (beta = –.21, p < .001), COVID-19 related stress (beta = .36, p < .001), and mental health (beta = −.23, p < .001) predicted pregnancy-specific stress. See Supplement 3.

      General stress

      Sociodemographic factors entered at Step 1 explained 8.1% of the variance in general stress. After entry of the COVID-19 related stress, pregnancy-specific stress, social support, and mental and physical health at Step 2, the total variance explained by the model was 48.9%, F (23, 474) = 21.72, p < .001. The well-being factors explained an additional 43% of the variance in stress, after controlling for sociodemographic factors; R squared change = .43; F change (5, 474) = 84.06, p < .001. In the final model, COVID-19 related stress (beta = .12, p = .002), mental health (beta = −.59, p < .001) and physical health (beta = −.11, p = .003) predicted general stress. See Supplement 3.

      Perceived mental health

      Sociodemographic factors, entered at Step 1, explained 7.9% of the variance in mental health as measured by the SF-12. After entry of the stress measures, social support and physical health at Step 2, the total variance explained by the model was 52.1%, F (23, 474) = 24.54, p < .001. The well-being factors explained an additional 43% of the variance in mental health, after controlling for sociodemographic factors; R squared change = .43, F change (5, 474) = 89.60, p < .001. In the final model, gestational weeks (beta = .09, p = .006), pregnancy-specific stress (beta = −.15, p < .001), general stress (beta = −.55, p < .001), and physical health (beta = −.23, p < .001) predicted mental health. See Supplement 4.

      Perceived physical health

      Sociodemographic factors, entered at Step 1, explained 7.6% of the variance in physical health measured by the SF-12. After entry of the stress, social support, and mental health measures at Step 2, the total variance explained by the model was 19.5%, F (23, 474) = 6.24, p < .001. The well-being factors explained an additional 12.3% of the variance in physical health, after controlling for sociodemographic factors; R squared change = .123, F change (5, 474) = 15.20, p < .001. In the final model, gestational weeks (beta = −.23, p < .001), pregnancy-specific stress (beta = −.29, p < .001), general stress (beta = −.17, p = .003), and mental health (beta = −.38, p < .001) predicted physical health. See Supplement 4.

      Health-promoting behaviours

      Sociodemographic factors entered at Step 1 explained 10.2% of the variance in health-promoting behaviours. After entry of stress measures, social support, and mental and physical health (well-being factors) at Step 2, the total variance explained by the model was 24.8%, F (24, 473) = 6.52, p < .001. The well-being factors explained an additional 14.7% of the variance in health-promoting behaviours, after controlling for sociodemographic factors; R squared change = .147, F change (6, 473) = 15.39, p < .001. In the final model, having a technical or vocational qualification (beta = .17, p = .008) or a doctorate (beta = −.189, p = .004), physical health (beta = .24, p < .001), mental health (beta = .27, p < .001) and social support (beta = .12, p = .005) predicted health-promoting behaviours. See Supplement 5.

      Health-impairing behaviours

      Sociodemographic factors were entered at Step 1 and explained 12.3% of the variance in health-impairing behaviours. After entry of stress measures, social support, and mental and physical health at Step 2, the total variance explained by the model was 16.9%, F (24, 473) = 3.99, p < .001. The well-being factors explained an additional 4.5% of the variance in health-impairing behaviours, after controlling for sociodemographic factors; R squared change = .045, F change (6, 473) = 4.31, p < .001. In the final model, age (beta = −.17, p = .002), number of children (beta = .25, p < .001), being resident in the UK (beta = −.18, p = .007), and pregnancy-specific stress (beta = .19, p < .001) predicted health-impairing behaviours. See Supplement 5.

      Demographic differences in COVID-19 health behaviours

      Chi square tests conducted to examine potential demographic differences in COVID-19 related health behaviours indicated that wearing a mask when leaving home was significantly associated with relationship status (χ2(3) = 19.49, p < .001): married women were most likely to wear a mask. Wearing a mask was also associated with country of residence (χ2(3) = 87.30, p < .001), with women in America more likely to report wearing a mask than their counterparts in Ireland or the United Kingdom. Wearing a mask when in hospital/maternity services was also associated with the country of residence (χ2(3) = 41.08, p < .001): women in America were most likely to do so. Going to crowded places was associated with education (χ2(5) = 22.92, p < .001), women with a postgraduate degree being least likely to go to crowded places; and with country of residence (χ2(3) = 24.34, p < .001), women in Ireland being most likely to go to crowded places. Disinfecting and cleaning, leaving home only when essential, and avoiding handshakes/close contact were not significantly associated with any demographic factors. See Supplement 6 for complete details of findings regarding demographic differences in COVID-19 related health behaviours.

      Discussion

      This study examined pregnant women’s levels of stress, mental and physical health, and frequency of health behaviours during the COVID-19 pandemic. Building upon existing evidence that pregnant women are experiencing more anxiety, depression, and post-traumatic stress during the pandemic [
      • Berthelot N.
      • Lemieux R.
      • Garon-Bissonnette J.
      • Drouin-Maziade C.
      • Martel É
      • Maziade M.
      Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic.
      ,
      • Wu Y.
      • Zhang C.
      • Liu H.
      • Duan C.
      • Li C.
      • Fan J.
      • et al.
      Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China.
      ], this study found high levels of pregnancy-specific stress and COVID-19 related stress, but low levels of mental and physical health and social support. The majority of women in this study engaged in recommended prenatal health behaviours and COVID-19 related behaviours. Psychological outcomes and health-promoting behaviours were mostly predicted by well-being variables including stress and social support; sociodemographic factors had limited impact on outcomes.
      Our findings indicated that during the pandemic, pregnant women in our study were experiencing normative levels of general stress [
      • Wartting S.L.
      • Forshaw M.J.
      • South J.
      • White A.K.
      New, normative, English-sample data for the short form perceived stress scale (PSS-4).
      ], but reported high levels of pregnancy-specific stress [
      • Ibrahim S.
      • Lobel M.
      Conceptualization, measurement, and effects of pregnancy-specific stress: review of research using the original and revised prenatal distress questionnaire.
      ] and COVID-19 related stress. That prenatal and COVID-19 stress were heightened in this sample, but general stress was not, suggests that the experience of being pregnant during the pandemic may function as a contextual stressor. This is supported by our findings that nearly all participants reported feeling somewhat or very concerned about COVID-19/related restrictions, many were concerned about their babies becoming unwell due to the coronavirus, and many reported disruptions to sleep associated with thinking about the coronavirus. That is in line with previous evidence that the coronavirus has prompted pregnancy-specific concerns [
      • Corbett G.A.
      • Milne S.J.
      • Hehir M.P.
      • Lindow S.W.
      • O’Connell M.P.
      Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic.
      ,
      • Yassa M.
      • Birol P.
      • Yirmibes C.
      • Usta C.
      • Haydar A.
      • Yassa A.
      • et al.
      Near-term pregnant women’s attitude toward, concern about and knowledge of the COVID-19 pandemic.
      ]. More generally, our findings of increased COVID-19 related stress are in keeping with previous examinations that indicated high levels of anxiety during the pandemic [
      • Berthelot N.
      • Lemieux R.
      • Garon-Bissonnette J.
      • Drouin-Maziade C.
      • Martel É
      • Maziade M.
      Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic.
      ] as stress and anxiety are highly related, though distinct, constructs [
      • Glover V.
      Prenatal stress and the origins of psychopathology: an evolutionary perspective.
      ]. These findings provide insight on the specific content of women’s stress during the pandemic, and specifically suggest that stress reduction interventions which target pregnancy and coronavirus-related concerns may be particularly useful.
      In addition, although significant differences in stress were not previously observed between women pregnant before or during the pandemic in Ireland [
      • Matvienko-Sikar K.
      • Pope J.
      • Cremin A.
      • Carr H.
      • Leitao S.
      • Colander E.K.
      • Meaney S.
      Differences in levels of stress, social support, health behaviours, and stress-reduction strategies for women pregnant before and during the COVID-19 pandemic, and based on phases of pandemic restrictions, in Ireland.
      ], the current paper did not find any sociodemographic predictors of any stress outcomes in this international sample. This suggests that while experiences of stress during the pandemic may be contextually specific, they may not be place- or demographic-specific, a finding which suggests that population-level approaches to addressing and supporting prenatal mental health may be effective in the pandemic context. However, given the overall homogeneity of this sample in terms of ethnicity and education, and in light of existing evidence of the relationship between sociodemographic factors and mental health concerns [
      • Biaggi A.
      • Conroy S.
      • Pawlby S.
      • Pariante C.M.
      Identifying the women at risk of antenatal anxiety and depression: a systematic review.
      ], this likely bears further examination.
      In this sample, the strongest predictors of stress outcomes were other types of stress and general mental health. Stressors identified by participants included concerns about COVID-19 infection during pregnancy and/or in infants, limitations on travel and social contact imposed by public health restrictions, and limitations on access to prenatal care as a result of public health measures. Additional qualitative feedback from this sample (presented in a complementary paper) suggests that changes to antenatal care, conflict with social support networks, and feelings of uncertainty and isolation were also important sources of stress for this population [
      • Meaney S.
      • Pope J.
      • Leitao S.
      • Colander E.K.
      • Matvienko-Sikar K.
      Formal and informal supports for pregnant women during the pandemic: Social support and satisfaction with maternity services.
      ]. This suggests that the development and implementation of prenatal mental health supports and interventions should include a specific focus on pregnancy- and COVID-19-related concerns. Further, though our findings did not suggest an influence of demographic factors, predisposing psychological factors should be considered in the development and implementation of interventions.
      In line with previous findings about the relationship between prenatal stress and health outcomes [
      • Lobel M.
      • Cannella D.L.
      • Graham J.E.
      • DeVincent C.
      • Schneider J.
      • Meyer B.A.
      Pregnancy-specific stress, prenatal health behaviors, and birth outcomes.
      ], general stress was shown to have a significant impact on both mental and physical health in this sample. Notably, pregnancy-specific stress was also a significant predictor of mental health, suggesting that pregnancy-related concerns may put women at increased risk for mental health impairment and could be useful targets for mental health intervention in pregnant populations. This may be of particular significance as increased mental health symptoms have been reported in pregnant populations since the beginning of the pandemic [
      • Berthelot N.
      • Lemieux R.
      • Garon-Bissonnette J.
      • Drouin-Maziade C.
      • Martel É
      • Maziade M.
      Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic.
      ,
      • Wu Y.
      • Zhang C.
      • Liu H.
      • Duan C.
      • Li C.
      • Fan J.
      • et al.
      Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China.
      ]. In addition, our findings suggest a bi-directional relationship between mental and physical health. Previous findings have demonstrated associations between prenatal stress and engagement in health behaviours [
      • Lobel M.
      • Cannella D.L.
      • Graham J.E.
      • DeVincent C.
      • Schneider J.
      • Meyer B.A.
      Pregnancy-specific stress, prenatal health behaviors, and birth outcomes.
      ]. However, our findings indicate that despite high levels of pregnancy related and COVID-19 related stress, women in this study reported high adherence to health-promoting behaviours (e.g. eating healthily, exercising, taking vitamins). Similarly, women reported low engagement in health-impairing behaviours (e.g. alcohol consumption and smoking). This finding differs from two recent studies demonstrating lower reported physical activity during the pandemic [
      • Matvienko-Sikar K.
      • Pope J.
      • Cremin A.
      • Carr H.
      • Leitao S.
      • Colander E.K.
      • Meaney S.
      Differences in levels of stress, social support, health behaviours, and stress-reduction strategies for women pregnant before and during the COVID-19 pandemic, and based on phases of pandemic restrictions, in Ireland.
      ,
      • Davenport M.H.
      • Meyer S.
      • Mesh V.L.
      • Strynadka M.C.
      • Khurana R.
      Moms are not OK: COVID-19 and maternal mental health.
      ]. It is important to note that high levels of self-reported appropriate health behaviours may reflect socially desirable responding in the current study. Unlike stress outcomes, sociodemographic factors including education, number of children, and country of residence, were predictors of health-promoting and health-impairing prenatal behaviours in the current study. The finding that the number of children women have impacts health behaviours is likely related to childcare and caring responsibilities; as there is evidence that changes to schooling and childcare provision during the pandemic have placed significant strain on families with children [

      A. Sevilla, SS. Mith. Baby Steps: The Gender Division of Childcare During the COVID19 Pandemic. CEPR Discussion Paper No. DP14804. Available at SSRN: https://ssrn.com/abstract=3612873.

      ].
      Finally, while women generally reported very high levels of adherence to COVID-19 related health behaviours (such as social distancing, wearing masks, and disinfecting surfaces), some sociodemographic differences in adherence were observed. Observed associations between some pandemic-related behaviours (avoiding public places and wearing masks) and country of residence, suggest that national guidance, regulations, and sociocultural contexts may significantly impact on pregnant women’s health-related decision-making during the pandemic. Unlike the findings related to stress outcomes, these findings suggest a need for potentially more targeted interventions within countries and groups to improve and/or maintain appropriate prenatal behaviours during a pandemic.

      Strengths/limitations

      The cross-sectional nature of this study is limited as we are unable to track how the pandemic may impact participants’ wellbeing- and behaviours over time/as perceived COVID-19 risk and restrictions change. In addition, while assessment of stress during the pandemic was conducted using validated measures of general stress and pregnancy-specific stress, there was not, at the time of data collection, a published validated scale to measure COVID-19 related stress in pregnant women. While the measure of COVID-19 related stress designed for this study had good internal validity, a validated measure of prenatal stress and anxiety has since been published [
      • Preis H.
      • Mahaffey B.
      • Heiselman C.
      • Lobel M.
      Pandemic-related pregnancy stress and anxiety among women pregnant during the coronavirus disease 2019 pandemic.
      ], and this would prove useful for future research in this area. We also did not assess whether women had received a positive COVID-19 test result, which might have influenced their well-being and behaviours.
      Furthermore, participants in this study were largely married or in a relationship, educated to degree-level or higher, socioeconomically advantaged, and resident in Ireland, the United Kingdom or America. Thus these results may tend to understate the economic and social drivers of stress and adherence to health advice during the pandemic. However, the international sample enhances generalisability of our findings and interpretations. In addition, our comprehensive approach to examining multiple types of stress and a range of health behaviours provides important insights into as yet under-examined aspects of women’s experiences of pregnancy during the pandemic.

      Conclusion

      This study found high levels of pregnancy-specific and COVID-19 related stress, and low levels of mental and physical health during the COVID-19 pandemic. In this sample, these variables were mostly predicted by well-being factors rather than sociodemographic factors. Pregnant women in this study reported good engagement with healthy behaviours and high adherence to COVID-19 public health recommendations during the pandemic.
      Our findings highlight the need for prenatal mental health supports that target pregnancy- and coronavirus-specific concerns, and that can be implemented at population levels to support prenatal mental health. While experiences of stress did not appear to be place- or demographic-specific in this study, the association between certain health behaviours (including mask-wearing and avoiding crowded places), and sociodemographic factors, suggest that some elements of prenatal health behaviour may be influenced by national guidance and cultural context, further illustrating the need for structured interventions for women pregnant during the pandemic. These supports are clearly greatly needed and may help to mitigate adverse effects for women and children.

      Author agreement

      The authors hereby certify that the work presented in this submission is the authors’ original work, has not been published (and is not under consideration for publication) elsewhere, and has been reviewed and approved by all authors. The authors also agree to abide by the copyright terms and conditions of Elsevier and the Australian College of Midwives.

      Author contributions

      KMS conceptualised and designed the study, collected and analysed the data, wrote and revised the final manuscript.
      JP contributed to study design, collected data and assisted with data analysis, and critically reviewed and revised the manuscript.
      EKO designed the study, contributed to analyses and critically reviewed and revised the manuscript.
      SL conceptualised and designed the study and critically reviewed and revised the manuscript.
      SM conceptualised and designed the study, contributed to analyses and critically reviewed and revised the manuscript.

      Funding

      This research is supported by an Evidence Synthesis Ireland and Health Research Board Trials Methodology Research Network COVID-19 Emergency Evidence Response Service Summer Scholarship. The research is also supported by a Health Research Board Applying Research into Policy and Practice Fellowship (HRB-ARPP-A-2018-011). The funders had no role in the design, conduct, analysis or interpretation of the research.

      Ethical statement

      All procedures were approved by the University College Cork School of Public Health Research Ethics Committee and the Clinical Research Ethics Committee of the Cork University Teaching Hospitals (Ref ECM 4 (zz) 10/01/12).

      Conflict of interest

      The authors have no conflict of interest to declare.

      Acknowledgement

      The authors would like to thank all the pregnant women who completed the survey.

      Appendix A. Supplementary data

      The following is Supplementary data to this article:

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