Social Problems during Pregnancy under the Coronavirus Disease 2019 Epidemic in Japan

Since 2016, the frequency of pregnant women with social problems, who are recognized as “specific expectant mothers, i.e., pregnant women with at least one social risk factor (1), (2), ,” have increased significantly year by year. The breakdown of high-risk factors associated with their difficulty raising children has been almost unchanged; however, in 2020 the impact of the Coronavirus disease 2019 (COVID-19) epidemic may be too great to continue the factors. Therefore, we examined the changes in status of the social problems and our support under the COVID-19 epidemic. The study protocol was approved by the Ethics Committee of the Japanese Red Cross Katsushika Maternity Hospital. Informed consent concerning retrospective analyses was obtained from all subjects. In this study, we examined the frequency, associated factors, and outcomes of specific expectant mothers managed at our institute under the COVID-19 epidemic (from April to September 2020) compared with those in 2019 as reported previously . Data are expressed as numbers and percentages. The one-way analyses of variance were used. Differences with p < 0.05 were considered significant. Table 1 shows the number (frequency) of the specific expectant mothers managed at our institute and main social factors associated with the specific expectant mothers in the two periods (duplicate). In our previous study , the frequency of the specific expectant mothers increased significantly from 2016 to 2019 year by year (p < 0.01); however, it decreased significantly under the COVID-19 epidemic (p < 0.01); however, the frequency of the high-risk social factors remained almost unchanged between the recent two periods. Table 2 shows the occupations supporting the social factors associated with the specific expectant mothers (duplicate) and the number of mothers unable to raise children. In our institute, the percentage of required occupations increased significantly under the COVID-19 epidemic (p < 0.01). Based on the current results, the ratio of specific expectant mothers seemed to decrease under the COVID-19 epidemic; however, more active support was required for them. It may suggest that pregnant women in Japan may have more severe social and/or economic distress and social isolation than expected. They tend to avoid complaining about their problems on their own . Because this tendency has been presumed to be stronger under the COVID-19 epidemic, which restricts their behavior, their number/ratio might have decreased. Under these restrictions, pregnant women have greater social problems and we believe that an increasing number of pregnant women are in need of social support. According to the reports from our social workers, the women who were conspicuous were as follows: foreigners without medical insurance who could not return to their countries, hospitalized women with disabilities who cannot take care of themselves under visitation restrictions, teenagers who have unexpectedly become pregnant, etc. In addition, there were some pregnant women who refused support to avoid contact with others due to the COVID-19 epidemic. Therefore, a more proactive approach from medical institutions is needed to solve social problems of specific pregnant women under the COVID-19 epidemic.

Since 2016, the frequency of pregnant women with social problems, who are recognized as "specific expectant mothers, i.e., pregnant women with at least one social risk factor (1), (2), (3) ," have increased significantly year by year. The breakdown of high-risk factors associated with their difficulty raising children has been almost unchanged; however, in 2020 the impact of the Coronavirus disease 2019 (COVID-19) epidemic may be too great to continue the factors. Therefore, we examined the changes in status of the social problems and our support under the COVID-19 epidemic.
The study protocol was approved by the Ethics Committee of the Japanese Red Cross Katsushika Maternity Hospital. Informed consent concerning retrospective analyses was obtained from all subjects.
In this study, we examined the frequency, associated factors, and outcomes of specific expectant mothers managed at our institute under the COVID-19 epidemic (from April to September 2020) compared with those in 2019 as reported previously (3) . Data are expressed as numbers and percentages. The one-way analyses of variance were used. Differences with p < 0.05 were considered significant. Table 1 shows the number (frequency) of the specific expectant mothers managed at our institute and main social factors associated with the specific expectant mothers in the two periods (duplicate). In our previous study (3) , the frequency of the specific expectant mothers increased significantly from 2016 to 2019 year by year (p < 0.01); however, it decreased significantly under the COVID-19 epidemic (p < 0.01); however, the frequency of the high-risk social factors remained almost unchanged between the recent two periods. Table 2 shows the occupations supporting the social factors associated with the specific expectant mothers (duplicate) and the number of mothers unable to raise children. In our institute, the percentage of required occupations increased significantly under the COVID-19 epidemic (p < 0.01).
Based on the current results, the ratio of specific expectant mothers seemed to decrease under the COVID-19 epidemic; however, more active support was required for them. It may suggest that pregnant women in Japan may have more severe social and/or economic distress and social isolation than expected. They tend to avoid complaining about their problems on their own (4) . Because this tendency has been presumed to be stronger under the COVID-19 epidemic, which restricts their behavior, their number/ratio might have decreased. Under these restrictions, pregnant women have greater social problems and we believe that an increasing number of pregnant women are in need of social support.
According to the reports from our social workers, the women who were conspicuous were as follows: foreigners without medical insurance who could not return to their countries, hospitalized women with disabilities who cannot take care of themselves under visitation restrictions, teenagers who have unexpectedly become pregnant, etc. In addition, there were some pregnant women who refused support to avoid contact with others due to the COVID-19 epidemic.
Therefore, a more proactive approach from medical institutions is needed to solve social problems of specific pregnant women under the COVID-19 epidemic.

Author Contributions
Shunji Suzuki: project development, data management, data analysis, manuscript writing/editing. Masako Eto: project development, data collection, data analysis, manuscript writing/editing.

Consent
The study protocol was approved by the Ethics Committee of the Japanese Red Cross Katsushika Maternity Hospital (K2019-26-2).
Patients' informed consent for publication of this report was obtained.