Corona Virus Disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which was first identified in Wuhan, China. The rapid spread of the virus since its first detection in December 2019, had resulted in a global outbreak and the declaration of a pandemic by the World Health Organization (WHO) on 11 March 2020. To date, around 188 million people were infected worldwide with four million recorded mortalities (1). Malaysia reported over nine hundred thousand cases with a death rate of 0.77% (2).

Public health measures such as accurate and early detection of SARS-CoV-2, combined with isolation and contract tracing of positive cases, are essential to prevent further community spread (3). Mass quarantine is also implemented by authorities in the effort to reduce COVID-19 transmission. Similar to other countries, the Malaysian Government had implemented nationwide lockdown in the form of movement control order (MCO). The MCO involved the closure of the international border as well as all educational and business premises (4). Any mass gathering was strictly prohibited and only selected providers of essential services such as food, health, telecommunication, and transportation were allowed to operate (5).

The risk of severe coronavirus disease 2019 (COVID-19) among pregnant women may be higher than in the general population. Physiological and immunity changes during pregnancy increase the women's susceptibility to severe disease (6). Data from the United States' Centre for Disease Control and Prevention (CDC) indicated that pregnancy was significantly associated with an increased chance of ICU admission, the need for invasive ventilation, and maternal mortality (7).

The combination of disease pandemic and national lockdown would inevitably lead to psychological distress and a low state of wellbeing among pregnant women (8). Psychological wellbeing is a mixture of pleasant emotion and the ability to function effectively in the personal and social domain (9). The nature of psychological wellbeing is multi-dimensional, which includes a sense of control, supportive social relations, and general satisfaction with life (10). Previous studies have demonstrated the negative correlation between psychological wellbeing and distress (5, 10). Labrague et al. found that higher levels of fear of COVID-19 were associated with increased psychological distress, lesser job satisfaction, reduced health perceptions and greater turnover intention (11).

Risk of COVID-19 transmission to self and fetus alongside uncertainties about deliveries, loss of household income, and domestic conflict was among the stressors which contributed toward pregnancy-related anxiety (12). Studies conducted during the first wave of the pandemic showed an increase in the prevalence of depression and anxiety among pregnant women (13–15). Wu et al. found that the depressive rates were positively associated with the number of newly-confirmed COVID-19 cases and fatalities (15). Primiparity, younger age, lack of social support, and previous psychiatric diagnosis were among the risk factors for maternal depression and anxiety (14).

Evidence shows that prenatal psychological distress affects both maternal and fetal wellbeing, with a potentially long-term effect on child development (16, 17). Maternal stress in pregnancy may lead to poor maternal psychosocial function and parenting difficulties, whilst adverse effects on the fetus include growth restriction, alteration in brain development, prematurity, and low birth weight (18). Recent evidence has demonstrated the negative impact of prenatal depression and anxiety on the socio-emotional (19) and cognitive development of the offspring (20); with an increased risk of depression in adolescence and adulthood (21). Therefore, in this era of the COVID-19 pandemic, maternal mental health wellbeing should be considered an important public health issue. We aimed to assess the prevalence of psychological distress among Malaysian pregnant women during the COVID-19 nationwide lockdown. Our study objectives also included the evaluation of maternal COVID-19 pregnancy-related anxiety and the impact of MCO on their psychological wellbeing.

We conducted a cross-sectional study during the Malaysian MCO; from May 2020 till June 2020 among women who received obstetric care in a teaching hospital in Kuala Lumpur. Prior study approval was obtained from the Ethics Committee of Universiti Kebangsaan Malaysia (FF-2020-211). The inclusion criteria were pregnant Malaysian women aged above 18 years old and able to understand the Malay language, whilst exclusion criteria were women with abnormal fetuses or stillbirth. Participants recruitment was conducted among women who: (1) attended the outpatient clinic for an antenatal appointment, and (2) admitted to the obstetric ward for delivery or other medical complications. Eligible women were invited to complete the electronic version of the questionnaire through Google form, which contained a consent section. Socio-demographics and clinical data were included in the data collection. We also evaluated the maternal knowledge, perception, and practice during the COVID-19 pandemic as part of this research and the relevant results had already been published (22).

We approached four-hundred and fifty women for this study and 93% completed the questionnaire. Five women were excluded due to incomplete data; resulting in a total number for analysis of 415. The demographic and clinical characteristics of our cohort are demonstrated in Table 1. The mean (SD) age for our women was 32.4 (4.5) and the majority (85%) were Malays. Over three-quarters of our women received tertiary education and were employed. Around 60% of participants were pregnant whilst the remaining was post-partum. The mean (SD) gestation was 31.8 (8.3) weeks. Almost two-fifths of our women had medical or obstetric complications. Table 1 also depicts the social support received by the women. The majority of women received family support (92%). The proportions who reported employer and government support were 49 and 61%, respectively. Our study also found that around 95% of our participants demonstrated adequate knowledge of COVID-19.

The COVID-19 outbreak and nationwide lockdown had a significant psychological impact on vulnerable groups such as pregnant women. We presented the first study which evaluated the effect of the global pandemic on maternal mental health among Malaysian women. Our results demonstrated that Malay women had a lesser odd of experiencing psychological distress and were more likely to report a greater sense of maternal wellbeing. Women of higher socioeconomic status reported a higher sense of maternal wellbeing; however, they were also more likely to experience the negative effect of the lockdown. We also found that there was a high level of COVID-19 pregnancy-related anxiety among our women especially among the young and Malay mothers; as well as those who had sufficient knowledge on COVID-19.

Various studies on maternal mental health during the global pandemic showed an uptrend in the symptoms of psychological distress. A recent systematic review by Suwalska et al. found that the prevalence of depression and anxiety among perinatal women were as high as 56.3 and 77%, respectively (14, 34, 35). Current evidence also showed that the rate of psychological distress was positively correlated to the reported number of positive COVID-19 cases and related deaths (15, 36). This could explain the relatively low prevalence of depression and anxiety among our women, as this study was conducted in the early part of the COVID-19 pandemic in Malaysia, during which the country had just over eight thousand confirmed cases with only one-hundred twenty mortalities.

The COVID-19 outbreak had inevitably changed the delivery of health services including obstetric care. Hospitals had to ensure adequate resources to fight the pandemic by canceling elective procedures and outpatient clinics. Alteration to antenatal appointments (12) as well as uncertainty and concerns about perinatal care (37) were among the contributory factors of maternal depressive and anxiety symptoms. The absence of a partner during childbirth was also associated with a higher level of maternal anxiety (38). Several studies including ours have demonstrated the role of social support in reducing the risk of depression and anxiety among expectant mothers (37, 39, 40). Social support is essential in buffering the effect of stress in pregnancy as well as promoting maternal physical and psychological wellbeing (41). Women with a greater number of social support in our study demonstrated higher wellbeing scores, although the finding was not statistically significant.

In keeping with the previous study, we found a significant negative correlation between the SWEMWBS score and all the components of DASS 21 (3). Malay women and those of higher economic status reported a greater sense of maternal wellbeing in this study. Berthelot et al. demonstrated that pregnant women with low income were more prone to elevated distress and psychiatric symptoms during the COVID-19 pandemic (13). A Study conducted among Japanese women also found an increased odd of postnatal depression among those from the lower-income group (OR, 1.43; 95% CI: 1.03–1.98) (42). Although there was no significant difference in the psychological distress among women of different income brackets in our cohort, higher household income contributed to greater financial security to expectant mothers and resulted in an increased sense of wellbeing.

Nationwide lockdown had a significant socio-economic impact on the population. Closure of offices and business premises resulted in job losses and financial insecurity, whilst reduced family contact and restricted recreation activities would increase emotional stress.

Our study demonstrated that the lockdown has a negative effect on maternal wellbeing. We found that women with higher education and income level experienced a greater negative effect of MCO. These expectant mothers with higher economic status were more likely to have to work from home and found their social activities restricted during the lockdown. Multiparous mothers also demonstrated higher MCO effect scores compared to first-time mothers. Lack of childcare and online classes for school-going children might pose extra pressure on these mothers during the pandemic.

Over four-fifths of our women expressed worry about the risk of COVID-19 infection to themselves and their babies. Lebel et al. found that elevated symptoms of depression symptoms were associated with an increment in maternal concern on the COVID-19 threat to own life and potential harm to the baby (37). A study among pregnant individuals in Singapore during the early wave of the pandemic showed that women who associated COVID-19 infection with fetal anomalies and intrauterine fetal death had significantly higher anxiety scores (43). A study among Italian pregnant women during the COVID-19 national lockdown demonstrated that prenatal attachment negatively correlates with maternal state anxiety and depression. However, adequate and functional perception of COVID-19 could enhance prenatal attachment (44). The maternal-fetal emotional attachment is an important indicator of their health and the mother's efficiency in the postnatal period (45).

Currently, observational data have not suggested any link between COVID-19 and miscarriage, fetal anomaly, or spontaneous preterm births. Vertical transmission is plausible; however, the mechanisms are unclear and severe neonatal COVID-19 disease is fortunately rare (6). It is therefore important to fill the knowledge gap on the effect of COVID-19 on pregnancy by providing accurate and reliable information to expectant mothers. The younger and nulliparous women would benefit from extra support and reassurance as these groups exhibited a greater level of anxiety; in keeping with other studies (15, 42).

Our study evaluated the effect of adequate COVID-19 knowledge on maternal psychology during the pandemic. Liu et al. demonstrated that pregnant women with relatively more knowledge on COVID-19 and rational risk perception (not too nervous about epidemic control or going out) were less likely to be anxious (46). We found that individuals with adequate knowledge were more likely to report a greater sense of maternal wellbeing (OR 2.60, 95% CI 1.07–6.30, p = 0.034), however, the relationship was not significant following adjustment for age, ethnicity, and parity. These women also reported a higher level of COVID-19 pregnancy-related anxiety; which can be explained by the lack of available data on the effect of COVID-19 on pregnancy during the early wave of the pandemic.

Women's cultural background, which is influenced by race and religion; often plays a role in maternal perception, practice, and attitude toward the COVID-19 pandemic. Our previous published findings demonstrated that Malay women demonstrated a more positive attitude toward the MCO (22). A study from our neighboring country Singapore showed that pregnant Malay women were more likely to practice safe distancing and frequent hand sanitizing compared to the Chinese (47). The Malay women in our cohort were less likely to suffer from psychological distress. They also reported a greater sense of maternal wellbeing and experienced lesser negative effects from the lockdown. Good underlying knowledge on COVID-19 as well as high confidence in authority and health professionals among these women may explain the current findings (22).

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The studies involving human participants were reviewed and approved by Universiti Kebangsaan Malaysia Ethics Committee. The patients/participants provided their written informed consent to participate in this study.

AK, RA, and ZM: conceptualization. AK, SAS, and SS: methodology. AK and SS: formal analysis. AK and SAS: investigation. AK: writing—original draft preparation and project administration. AK, RA, ZM, and SS: writing—review and editing. RA: supervision. All authors have read and agreed to the published version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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