The emergence of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) firstly appeared in Wuhan, Hubei province, China, in late December 2019 (1). Within just a few months, it has already evolved into a pandemic. As of December 2021, more than 281 million confirmed cases and 5 million deaths have been reported (2). Since the COVID-19 is a highly infectious respiratory disease, isolation is needed to reduce the disease transmission of the COVID-19 pandemic, especially to the vulnerable groups. In addition, social isolation reduces the peak in COVID-19 cases (3).

Pregnant women are considered a vulnerable group for contracting the SARS-CoV-2 (4). In addition, they have increased risk of developing severe illness from COVID-19 when compared to non-pregnant individuals (5). The findings might be due to the physiologic changes in pregnancy including decreased lung capacity, increased heart rate, increased risk for developing thromboembolic disease. Therefore, higher adverse outcomes associated with COVID-19 including morbidity and mortality rate has been reported in pregnant women (6).

World Health Organization has recommended social isolation between individuals, especially in COVID-19 heavily-affected areas to reduce the mortality rate (7). Although social isolation reduces the transmission of SARS-CoV-2 between individuals, a significant reduction in social relationships would make them feel lonely and abandoned (8). Studies have reported that pregnant women are susceptible to stress and emotional instability (8–11). Therefore, it is suggested that social isolation can cause pregnant women to develop anxiety and depression. Therefore, the COVID-19 pandemic has posed huge and complicated challenges associated with mental health, quality of life and lifestyle changes among pregnant women (4–6).

Previous studies reported the stressful impact in the general population during the early stages of COVID-19 pandemic, and their stressful impact continued to increase over time from January 2020 until April 2020 (1, 12, 13). However, there have been few studies that have reported the mental well-being of pregnant women amidst the early stages of the COVID-19 pandemic (11, 14). During the severe acute respiratory syndrome (SARS) epidemic in 2004, higher rates of death and complications were reported in pregnant women when compared to non-pregnant individuals (15, 16). As the COVID-19 pandemic is still ongoing, there are rising concerns over an increase in stressful impact among pregnant women. Therefore, the aim of the present study was to determine the psychological impact and quality of life among pregnant women amid the early stages of the COVID-19 pandemic.

Quantitative data were collected using a cross-sectional study design which was administered between July 2020 and August 2020 on the Chinese social media platform. Only pregnant of Chinese nationality aged ≥18 years who were Chinese-speaking were eligible for the study. Sampling methods including convenience and snowball samplings were employed in the study. No nmonetary incentives were given to participants for their study participation. The minimum number of participants needed for the study was calculated using the formula as described by Naing et al. (17). The research study protocol was reviewed and approved by the Ethics Committee of the Baoji Maternity and Child Health Care Hospital, and performed in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) and CHERRIES guidelines (18).

Our study investigated the psychological impact of the pregnant women in mainland China amid the COVID-19 pandemic during the early stages of the pandemic. In addition, our study provided some nationwide data on the stressful impact and social support in pregnant women. Since the COVID-19 outbreak, an increase of 20% in mental illness cases has been reported in populations (22). However, there are few studies that have investigated the impact of the early stages of COVID-19 pandemic on mental health and quality of life in pregnant women, who have increased risk of developing certain morbidities from COVID-19 because of their physiological changes during pregnancy (11, 23–25). Factors such as inability to purchase food items, fear of becoming sick, and isolation of lockdown may also increase psychological distress, especially among pregnant women with lower socio-demographic status (23). In addition, they have higher risk of suffering poor mental health conditions amid the COVID-19 pandemic (23).

In our study, the overall mean IES was 30.6 ± 12.8 and 63.9% of participants had an IES score ≥26, which provided evidence that our pregnant women experienced moderate-to-severe stressful impact amid the early stages of the COVID-19 pandemic. A study by Wu et al. reported that Chinese pregnant women had higher rate of depressive symptoms amid the COVID-19 pandemic (25). In addition, the authors reported that the COVID-19 pandemic significantly increase the risk of thoughts of self-harm in pregnant women (25). It is suggested that pregnancy is also a factor that can increase vulnerability for developing mental health disorders including anxiety and depression (8).

Our study findings had identified increased stressful impact among pregnant women, which highlighted the strong needs and potential interventions to improve their mental health during this extremely difficult period. Due to the unpredictable nature of the COVID-19 situation, it can trigger some psychological and mental health distresses (1, 13). Several studies reported that exposure to COVID-19 pandemic and its impact on daily life aspects including quality of life, relationship, lifestyle, family and social support are some of the important predictors of the mental health issues (1, 11, 12, 20, 26). Mental health disorders are considered a common cause of morbidity in pregnant women with 22% of women experiencing anxiety and 12% of women experiencing depression (27, 28). It is possible that since pregnant women are more vulnerable to infections during pregnancy due to their naturally suppressed immune system, pregnant women are more likely to be psychologically affected because of the increased morbidity and mortality rate of COVID-19 reported. In addition, they are also further vulnerable to anxiety because of the increased concern about the possible vertical transmission of SARS-CoV-2 to their fetus (25).

Our study reported that overall there was increased family and social support received among pregnant women amid the COVID-19 pandemic. Our results were in line with other studies which reported that amid the COVID-19 pandemic, individuals were more likely to care for their family members' feelings and share their feelings with family members (1, 11, 26). It is suggested that amid the COVID-19 lockdown period, the slower pace of life allows individuals to spend more time supporting and connecting with their family members and friends (1, 26). Therefore, more qualitative and thorough research studies are needed to understand the possible mechanisms behind these findings.

Strengths of our study included the use of validated modified questionnaire to assess psychological impact and quality of life in pregnant women. In addition, our study was one of the first studies to investigate the psychological health impact of the COVID-19 pandemic among pregnant women within the Chinese context. Since our study only involved Chinese pregnant women, our results may not reflect the psychological impact of the larger population of pregnant women from different countries with different severity of COVID-19 pandemic. This is because pregnant women from different countries might experience different severity levels of COVID-19 pandemic and maternal healthcare support provided by the healthcare systems in their countries. On the other hand, pregnant women might more likely to cope with the stress during the COVID-19 pandemic due to the support received from family members and friends, even without the COVID-19 pandemic. Therefore, we recommend more exploratory studies on the mental health status and its associated factors amid the COVID-19 pandemic among pregnant women because these findings are imperative to designing appropriate mental health education for mitigating negative mental health consequences. Our study did not assess the vaccination willingness/status in pregnant women; however, this might have an impact on the quality of life in pregnant women. Therefore, future studies should investigate if there is a difference in quality of life between pregnant women who had and had not been vaccinated against SARS-CoV-2 (29, 30). The association of the support received from family and friends with stress from work, home and financial aspects in pregnant women with different severity of IES scores should be investigated in larger studies. The use of convenience sampling in our participant recruitment may be associated with sampling bias, which limits the generalizability of our findings. In addition, since our results were derived from a cross-sectional study design, it is very challenging and difficult for our study to draw causal inferences. Therefore, our study findings need to be interpreted with caution.

In conclusion, the COVID-19 pandemic has caused several psychological impacts on Chinese pregnant women. Our study provided significant insights regarding the quality of life in pregnant women who remain at high threat for developing mental health problems amidst the pandemic. We recommend that a thoughtful planning and time preparation by the government would definitely help to reduce the negative impacts caused by the COVID-19 pandemic and restore the quality of life among pregnant women.

The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.

The studies involving human participants were reviewed and approved by Ethics Committee of the Baoji Maternity and Child Health Care Hospital. The patients/participants provided their written informed consent to participate in this study.

JM, AW, and HZ: conceptualization, formal analysis, methodology, writing—original draft, writing—review, and editing. All authors contributed to the article and approved the submitted version.

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.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.