Posttraumatic Stress Disorder, Depression and Fear Of COVID-19 Among Pregnant Women During the Rapid Rise Period of the Coronavirus Pandemic in a Middle Eastern Country: A Cross-Sectional Study

Background: Coronavirus disease 2019 (COVID-19) is an emerging public health issue. Pregnant women are susceptible to its negative psychological impact. Particularly, pre-natal psychological health is critical as it can affect the well-being of the mothers and their fetuses. The present study aimed to assess the Covid-19 psychological impact on pregnant women, including posttraumatic stress disorder (PTSD), depression, and fear related to COVID-19 as well as to investigate their associated factors. Methods A cross-sectional study was conducted among pregnant women in Lebanon between 17th November 2020 and 27th February 2021. A standardized questionnaire was used to collect data about participants’ baseline characteristics and psychological status, including PTSD, depression as well as fear related to COVID-19. Results Out of the 466 respondents, 28.5% (n = 133) had PTSD related to Covid-19, and 22.1% (n = 133) had depression. The mean score for the fear of Covid-19 was 18.51 ± 5.55. Pregnant women’s depression and fear of Covid-19 were significantly associated with PTSD (adjusted OR = 5.85 with 95% CI of 3.37 to10.16;adjusted OR = 1.19 with 95% CI of 1.13 to 1.26, respectively). Furthermore, smoking during pregnancy and encountering difficulties in accessing healthcare during the pandemic were found to be associated with depression, while practicing home quarantine was found to be associated with the fear of Covid-19. Pregnant women who perceived high risks towards Covid-19 and those who experienced PTSD had high levels of both depression and the fear of Covid-19 compared to their counterparts. Conclusion High levels of PTSD, depression, and fear of Covid-19 were detected among Lebanese pregnant women. This recommends further psychological interventions to mitigate these levels.

Disease outbreaks have been suggested to have a potentially negative emotional impact on pregnant women [2]. Compared to the pre-Covid-19 period, pregnant women assessed during the Covid-19 pandemic displayed high levels of anxiety and depressive symptoms in addition to symptoms of posttraumatic stress disorder [3]. Furthermore, in a survey aiming to investigate the fear of Covid-19 among pregnant and infertile patients in Japan, Asai et al found that Japanese pregnant women had a higher fear of Covid-19 scores than Japanese infertile patients [4].
Pre-natal psychological health can affect the neurobehavioral development of the fetus and, therefore, the outcomes for the child [5]. Premature brain development was assumed in children of mothers who experienced higher perinatal depressive symptoms [6], and slower growth of the right and left hippocampus was detected during the rst six months of life in children of mothers who reported increased anxiety during pregnancy [7]. Consequently, these long-lasting behavioral and structural changes highlight the importance of mental health assessment in pregnant women during this stressful outbreak.
Pregnant women consider pregnancy to be a risky time in their lives during which they are susceptible to a wide range of physical and psychological threats. Due to the negative emotional impact of the COVID-19 pandemic on pregnant women, signi cant efforts are ongoing to better investigate their mental health status during this global outbreak.
In research carried out in China, low levels of PTSD, anxiety, depression, insomnia, and physical discomfort were detected among pregnant women during the Covid-19 outbreak [8]. However, in Italy, Saccone et al reported that the Covid-19 epidemic had a moderate to severe psychological impact (PTSD symptom) on pregnant women [9].
In Lebanon; a Middle Eastern country, a high rate of infected pregnant women was reported by the Ministry of Public health of which several cases of death have occurred. So far, no studies have been conducted to assess the psychological status of this vulnerable group. Thus, the present study intends to assess the Covid-19 psychological impact on pregnant women during the rapid rise phase of the Covid-19 pandemic, including PTSD related to COVID-19, depression, and fear of COVID-19 as well as to investigate their associated factors. The results of this study may provide health policymakers with relevant information on the psychological status of this group during the current pandemic.

Study design and population:
The present study is a cross-sectional study conducted in Lebanon from 17th November 2020 to 27th February 2021. Because of the strict measures imposed by the Covid-19 pandemic, the questionnaire was conducted online using a google form and the call for participation was made via social media platforms using the snowball technique. The inclusion criteria included Lebanese pregnant women with the ability to read and write. Any woman who was diagnosed with mental illness was excluded.
Ethical approval: Ethical approval for the study was obtained from the Institutional Review Board (IRB) committee of the Lebanese University Faculty of Medical Sciences (Reference number 62/2 /2021). All the collected data were kept con dential.

Sample size calculation:
Considering an anticipated response of 50%, a con dence level of 95%, a margin of error of 5%, and an estimated population of 125,000 [10], the required sample size of this survey would be at least 383; it was computed using the online RAOSOFT sample size calculator.

Instrumentation:
To collect the data, a questionnaire was originally prepared in the English language, then translated to the native language in Lebanon (Arabic). The study questionnaire was developed following a review of literature on COVID-19 [11][12][13][14]. The survey questionnaire covered the following areas: 1. Baseline characteristics including age, residence, education, work status, income level, gestational age, gravida, miscarriage loss, smoking status, and complications during pregnancy. Furthermore, all participants were asked whether they were infected with COVID-19 and if they were quarantined during the pandemic. Also, they were questioned about whether their monthly family income had been affected by COVID-19 and whether they were following the news of the global outbreak.
2. To evaluate the risk perception of pregnant women during the COVID-19 outbreak, a risk perception questionnaire was used. Each item was scored on a 5 point-Likert scale with total scores ranging from 0 to 40 and the higher the scores, the higher the risk perception level. This questionnaire has shown good reliability [15]. The internal consistency of the items was evaluated in our sample, and Cronbach's alpha was 0.674.
3. Assessment of PTSD: posttraumatic stress disorder related to the COVID-19 questionnaire (COVID-19-PTSD) with its 19 items was used to evaluate PTSD risk related to the current COVID-19 emergency. All items were answered by referring to the previous seven days during the COVID-19 outbreak. It is scored on a 0-4 Likert scale with a total score ranging from 0 to 80; a cutoff score of 26 indicates the presence of PTSD. The COVID-19-PTSD questionnaire has revealed excellent convergent validity, as well as reliability [16]. In this study, the internal consistency coe cient was excellent with a Cronbach's alpha of 0.933. 4. Participants' depression severity level was assessed by using a self-administered questionnaire "the Patient Health Questionnaire (PHQ9)'' with 9 items scored as 0 (not at all) to 3 (nearly every day) and a total score ranging from 0 (absence of depressive symptoms) to 27 (most severe depressive symptoms) (i.e., normal = 0-4; mild = 5-9; moderate = 10-14; moderate to severe = 15-19; and severe = 20-27) [17]. PHQ9 is a valid and reliable tool among the Lebanese population; ≥10 was adopted as the cut-off score to investigate the presence of depression [18]. The internal consistency of the items was evaluated in our sample, and Cronbach's alpha was 0.894. 5. Pregnant women's fear towards COVID-19 was investigated by using the seven questions of the fear of COVID-19 scale (FCV-19S). The scale requires a response on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The overall fear score is between 7 and 35 with higher scores indicating greater levels of fear towards COVID-19. The validity and consistency of the Arabic version of FCV-19S have been evaluated among the Saudi population [19]. In this study, the internal consistency coe cient of the FCV-19S was investigated, and Cronbach's alpha was 0.872.
Pilot study: The study was pretested in a sample of 6 pregnant women to check the clarity and readability of the questionnaire. Pregnant women did not report any problem concerning the clarity and the comprehensibility of the items. All the questions were completed within approximately 10 minutes.
Data collection: Data collection was performed using an online survey. The rst page of the online questionnaire consisted of a brief background about the study and its aims. The right of the participants to withdraw at any time in addition to their con dentiality and anonymity were respected. All individuals who were willing to participate in this study were asked to provide their agreement through informed consent.
Statistical analysis: The collected data were entered into the statistical software SPSS (Statistical Package for Social Sciences), version 25 for analysis. Means and standard deviations (SD) for continuous variables, while frequency (n) and percentages (%) for categorical variables were calculated for descriptive purposes.
Multivariate logistic regression analysis was carried out to identify factors related to PTSD and depression, whereas multiple linear regression analysis was performed to investigate factors associated with fear of Covid-19. Adjusted odds ratio and unstandardized regression coe cients (β) with their 95% con dence intervals were computed to present the results of multivariate analysis. A p-value of less than 0.05 was considered statistically signi cant.

Results
Characteristics of study population: The baseline characteristics of the participants are shown in Table 1 Concerning COVID-19, 7.1% of the participants were infected with coronavirus and 14.2% had di culty accessing healthcare during the pandemic. Moreover, 56.9% of the pregnant women reported that the outbreak had affected their monthly family income and 86.9% indicated that they were following the news of this global epidemic. Factors associated with PTSD symptomatology among pregnant women  their counterparts. In addition, smoking during pregnancy and encountering di culties in accessing healthcare during the pandemic were found to be associated with depression, while practicing home quarantine was detected to be related to fear of Covid-19. Interestingly, pregnant women who perceived high risks towards Covid-19 and those who experienced PTSD had high levels of both depression and the fear of Covid-19 compared to their counterparts.
In the present study, 28.5% of pregnant women were suffering from PTSD related to Covid-19. This result is relevant to the ndings obtained by a study conducted in Italy, where 29.5% of the Italian population suffered from PTSD; it's of utmost importance to mention that this study is the one that validated the PTSD-COVID-19 questionnaire and indicated a cutoff score of 26 that was used in our survey [11]. The prevalence of PTSD in a study carried out among pregnant women from all regions in China during the early phase of the Covid-19 pandemic (from 13 to 16 February 2020), was 40%, which is higher than the one obtained in our survey [20]. However, another study conducted among the Chinese pregnant women during the reducing stage after the Covid-19 epidemic's peak in China (from February 28 to March 12), revealed a percentage of PTSD of 0.9%, which is much lower than that found in our study [8]. This discrepancy in the prevalence estimates might be attributed to cultural differences and pandemic phases.
Multiple logistic regression analysis showed that pregnant women who experienced depression and had a high score of the fear of Covid-19 displayed a higher level of PTSD than their counterparts. This indicates that participants with high levels of depression and fear related to Covid-19 are at an increased risk of developing PTSD. A concurrent diagnosis of PTSD and depression was demonstrated in a study carried out by Gros et al [21]. Interestingly, our survey demonstrated fear as a predictor of PTSD, but not of depression; this is consistent with the result of research that showed impaired fear inhibition as a biomarker of PTSD but not depression [22]. Therefore, these data demonstrated a negative emotional impact of Covid-19 on pregnant women that calls for the need to evaluate the psychiatric characteristics of such a group during the Covid-19 period. Also, it entails the urgent need for psychological interventions to enhance the mental health status of pregnant women and avoid any complications that may affect the well-being of themselves and their fetuses.
Concerning depression, approximately 22% of the participants were suffering from depression during the Covid-19 pandemic; this prevalence is in line with the one found among healthcare workers at a tertiary care hospital in Lebanon [23]. Even though it seems to be lower than the results obtained in a study conducted among pregnant women in Sari and Amol, Iran, it is higher than the one found among Sri Lanka pregnant women [24,25] The current study has some limitations. Due to its cross-sectional nature, we are not able to make a cause-effect relationship. Also, the individuals were not randomly selected for participation making our ndings not generalizable. Another limitation is that not all used scales have been validated in Arabic. Furthermore, this study was carried out at a particular point in time, which demonstrates the need for longitudinal studies to follow up on the psychological status of pregnant women during this pandemic.

Conclusion
The present study revealed important insights into pregnant women's psychological status, including PTSD related to Covid-19, depression, and the fear of Covid-19. Lebanese pregnant women showed high levels of PTSD, depression, and fear during the rapid rise period of the coronavirus pandemic in Lebanon. This recommends the implementation of psychological interventions to enhance their mental health status and avoid any complications that may affect the well-being of them and their fetus. to answer a yes-no question to con rm their willingness to participate voluntarily. All the necessary measures to safeguard participants' anonymity and con dentiality of information were respected. Written informed consent approved by the ethics committee was obtained from all the participants.

Consent for publication
Not applicable.
Availability of data and materials Data are available from the corresponding authors upon reasonable request.

Competing interests
The author(s) declare that they have no competing interests.

Funding
No funding was received.
Author's contributions ZB and LAA developed the project idea, performed the literature review, formulated the questionnaire, organized and analyzed the survey, drafted and critically reviewed the paper. YF reviewed the manuscript for important intellectual content. All authors read and approved the nal manuscript. Figure 1 The prevalence of PTSD among pregnant women during the Covid-19 pandemic. Figure 2