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Depressive symptoms and psychological distress from antenatal to postnatal period in women with high-risk pregnancy

A prospective study during the COVID-19 pandemic

Hamidia, Angela; Kheirkhah, Farzan; Faramarzi, Mahbobeh; Basirat, Zahra1; Ghadimi, Reza; Chehrazi, Mohammad2; Barat, Shahnaz1; Cuijpers, Pim3; O’Connor, Elizabeth4; Mirtabar, Seyyedeh Mahboubeh5

Author Information
doi: 10.4103/indianjpsychiatry.indianjpsychiatry_1272_2
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In January 2020, the World Health Organization declared the outbreak of the coronavirus disease 2019 (COVID-19) a public health emergency of international concern.[1] During the incidence of traumatic events, people are more likely to experience negative emotions.[2] There is a widespread consensus that the COVID-19 pandemic affects physical and mental health and well-being.[3] It has also been found that women are more likely to show signs of stress, anxiety, and depression.[4]

Prenatal and postpartum periods are vulnerable times that may increase the frequency of psychiatric disorders.[56] In addition, childbirth may be accompanied by stressful experiences where some women may have posttraumatic stress disorder (PTSD) in postpartum period following stressful labor experiences.[78] In women with psychiatric disorders, the risk of poor pregnancy outcomes increases, such as preterm birth, pregnancy loss, and intrauterine growth restriction.[91011] Also, evidence supports that psychosocial factors have essential risk factors for psychiatric disorders during pregnancy and postpartum periods.[121314]

Major health-threatening events, such as COVID-19 may increase psychiatric symptoms in prenatal and postnatal periods. In the 1st months of 2020, pregnant and breastfeeding women who faced the COVID-19 pandemic suffered from some additional stress, including the fear of infection, the unprecedented quarantine, and the fear of going into hospitals or clinics to receive medical consultation. These additional problems might have negatively impacted the emotional well-being of women and disturbed their personal and professional life. A study in China confirmed that pregnant women had significantly higher rates of depressive symptoms during the COVID-19 pandemic than before the pandemic.[15] In a review article, the symptoms of anxiety and depression were reported among 16%–28% of pregnant women.[16] A study in Belgium reported that the prevalence of depressive symptoms and generalized anxiety symptoms in pregnancy and postpartum was explicitly higher compared to estimates obtained before the COVID-19 pandemic.[17]

PTSD may occur in people who have experienced a traumatic event, such as a natural disaster, serious injury, and sexual violence. The PTSD symptoms include intrusive memories (flashback, recurrent, unwanted distressing memories of the traumatic event), avoidance (trying to avoid thinking or talking about the traumatic event), adverse changes in thinking and mood (negative thoughts about yourself, others, or the world), and arousal symptoms (irritability, hypervigilance, and trouble in sleep or concentration).[18] A cohort study reported that pregnant women during the COVID-19 pandemic would exhibit negative changes in thinking and mood, and arousal symptoms rather than intrusive memories and avoidance symptoms.[19]

The diagnostic and statistical manual of mental disorders (DSM-5) definition of PTSD has emphasized that “a life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event.”[18] Thus, the current definition excludes the COVID-19 pandemic as the basis for PTSD diagnosis. However, North et al. provided an in-depth nosological consideration of PTSD diagnosis. They presented three essential elements of PTSD regarding the mental health outcomes of the COVID-19 pandemic, including objective definitions of trauma and other stressors, objective definitions of exposure to trauma, and subjective emotional and psychological responses to trauma response.[20] Evidence advocates the nosological exploration of PTSD introduced by North et al. Much research considers fears related to the risk of exposure to COVID-19 as trauma and life-threatening stress.[212223] General populations and medical professionals have extensively reported that the risk of exposure to COVID-19 is a major source of apprehension and fear.[2425]

Although women with high-risk pregnancy appear to be at a higher risk of psychiatric disorders than those with low-risk pregnancy,[26] few prospective studies have reported the rate of psychiatric symptoms from prenatal to postnatal period in women with high-risk pregnancy.[27] To our knowledge, there is no published study assessing psychiatric symptoms in women with high-risk pregnancy during the COVID-19 pandemic. To the best of our knowledge, this is the first study comparing depressive symptoms and psychological distress in antenatal period before COVID-19 and in postnatal period after COVID-19. Accordingly, this study had three aims: (1) to assess depressive symptoms and psychological distress in antenatal period in women with high-risk pregnancy before COVID-19; (2) to investigate depressive symptoms and psychological distress in antenatal period in women with high-risk pregnancy after COVID-19; and (3) to estimate the PTSD prevalence during the COVID-19 pandemic in postpartum period.

Based on the framework described above, we proposed three hypotheses as follows:

  1. H0: There is no relationship between psychological distress in antenatal and postnatal periods.
  2. H1: There is a significant positive relationship between psychological distress in antenatal and postnatal periods.
  3. H0: There is no effect of pregnant women’s exposure to COVID-19 on the prevalence of depressive symptoms in postnatal period.
  4. H1: Pregnant women’s exposure to COVID-19 increases the prevalence of depressive symptoms in postnatal period.
  5. H0: There is no effect of pregnant women’s exposure to COVID-19 on the prevalence of PTSD in postnatal period.
  6. H1: Pregnant women’s exposure to COVID-19 increases the prevalence of PTSD in postnatal period.



This prospective study was conducted at a referral perinatal care centre, from December 2019 to June 2020. The study was part of the Screening and Management of Perinatal Depression Protocol, approved by the Ethics Committee of the institute. Written informed consent was obtained from all recruited participants before the study.

This study had two phases; prenatal screening and postnatal follow-up. The inclusion criteria were women diagnosed with high-risk pregnancy, age older than 18 years, and an educational level higher than primary school. In the first phase, we identified women with high-risk pregnancy and assessed the psychiatric symptoms. In the obstetric clinic of the hospital, we used a checklist confirmed by the Department of Obstetrics and Gynecology of the hospital to identify women at high risk of pregnancy.[28] In addition, women hospitalized in high-risk pregnancy units were invited to enter the study. According to the checklist, high-risk pregnancies were defined as the presence of one or more of the problems: Hypertensive diseases of pregnancy, gestational/pre-gestational diabetes, preterm ruptures of membranes, intrauterine growth restriction, multiple pregnancies, past adverse obstetric history, preexisting medical conditions, threatened preterm labor, thrombophilia, placenta previa, placenta abruption, or other risks for the mother or the fetus.[28]

Available sampling was used to recruit women with high-risk pregnancy. The sample size was estimated at 122 concerning the pilot information before the start of the study (ratio of depression 0.4, a =0.05, and d = 0.07). A member of the research team assessed the eligibility of women at the hospital. After explaining the study protocol and obtaining informed consent, she asked the women to complete two scales, including Edinburgh Postnatal Depression Scale (EPDS) and Brief Symptom Inventory 53-items (BSI-53). She asked them to fill in the scales again after giving birth (in 2–6 weeks of postpartum period).

The second phase was conducted to assess the changes of psychiatric disorders of the participants in postpartum period from February to June 2020. As the COVID-19 pandemic started in March 2020 in Iran, many of the women were not admitted to the obstetric clinic of the hospital to receive postpartum care. Thus, we had to contact them through online surveys.

The first author and a researcher (the tenth author) requested the participants to complete the scales. During 2–6 weeks of postpartum period, the researcher called the participants and invited them to complete the survey by filling in the scales. The researcher conducted this phase using the DigiSurvey® platform through a link sent to the women using Whattsapp® or Telegram. The women could freely choose to complete the scales. She sent three scales, including EPDS, BSI-53, and Primary Care PTSD screen (PC-PTSD-5), to all the participants of Phase 1 through a link. With women exposed to the trauma of the COVID-19 pandemic, we assessed PTSD. As we measured the PTSD symptoms during 2 months since the beginning of the COVID-19 pandemic, thus the critical aspects of PTSD were considered. Also, we considered women with a PC-PTSD-5 score of ≥3 as women with PTSD.

Unfortunately, only 41 of the participants filled in the scales. Also, the researcher suggested women filling in the scales at phase 2 with a score of EPDS ≥10 or PTSD-5 >3 to consult with a psychiatric resident of the hospital to conduct a structured clinical interview for DSM-5 to diagnose their mental disorders. Women diagnosed with mental disorders were given an appointment with a psychiatrist to receive appropriate treatment. Women diagnosed with mild to moderate mental disorders, for example, mild-to-moderate depressive disorders, received online cognitive behavior therapy. Also, pregnant women diagnosed with severe mental disorders, for example, severe depressive disorders or PTSD, received appropriate pharmacotherapy plus online cognitive behavior therapy.


Primary care posttraumatic stress disorder screen (PC-posttraumatic stress disorder-5)

It was used to assess PTSD among the participants during the trauma of exposure to COVID-19. Prins et al. demonstrated excellent diagnostic accuracy for PC-PTSD-5 compared to the DSM-5 of PTSD. The scale consists of five items, and each item has dichotomous answers (yes/no) with scores between 0 and 5. A cut-off score of PC-PTSD-5 ≥3 has maximum sensitivity for PTSD diagnosis.[29]

Edinburgh postnatal depression scale

We used EPDS developed by Cox et al.(1987) to assess prenatal and postnatal depression.[24] It consists of 10 items with a 4-point Likert-type scale ranging from 0 to 3. The total score of EPDS ranges between 0 and 30. The higher scores indicate greater depression symptoms.[30] In EPDS, we used a cut-off score of 13 or higher for the detection of depressive symptoms.[31]

Brief symptom inventory 53-items

Derogatis and Melisaratos (1983) developed BSI-53 as a short alternative for Symptom Checklist-90-Revised. The BSI-53 identifies nine psychiatric symptoms, including depression, anxiety, interpersonal sensitivity, somatization, obsession-compulsion, phobic anxiety, hostility, paranoid ideation, and psychoticism. Also, we measured global severity index (GSI) to assess psychological distress in the pregnant women. GSI was calculated by dividing the sum of scores of all questions by the number of questions. Psychological distress was defined as a T score for GSI of 63 or greater in BSI-53.[32]

Statistical analysis

Personal and psychological assessments of the pregnant women were summarized and presented by means and standard deviations. A Chi-square test was used to investigate changes in the frequency of depressive symptoms and psychological distress between antenatal and postnatal periods. Pearson’s correlation coefficient was applied to assess possible significant relationships between EPDS and BSI-53. A paired t-test was employed to compare the mean scores of depressive symptoms and psychological distress in antenatal and postnatal periods. Statistical significance was set at a P < 0.05. The statistical analyses were performed using SPSS version 24 software (SPSS, Chicago, IL, USA).


Table 1 reports the demographics of the pregnant women during Phase 1 (pregnancy) and Phase 2 (postpartum) of the study. About one-third of the women (41/122) participated in Phase 2. Most women of the two phases of the study had an educational level of high school.

Table 1
Table 1:
Demographic of participants and description of the psychological variables at two phases of the study

Of the 122 women with high-risk pregnancy assessed in antenatal period, 23 (18.9%) had total EPDS scores ≥13. Of the 41 pregnant women followed up at 2–6 months postpartum, 34 (82.3%) had EPDS scores above 13. Further, six of the seven pregnant women with antenatal depression within the total sample (n = 41) continued to have depression at postnatal assessment, indicating 85.7% persistence of depressive symptoms. Of the 41 women assessed in postnatal period, 35 had depressive symptoms, of whom 28 did not have antenatal depression. Thus, the prevalence of postnatal depressive symptoms is estimated 80% during the first acute phase of the COVID-19 pandemic. None of the 41 women who completed the scales in postnatal period was infected with COVID-19.

Table 2 indicates the frequency of depressive symptoms and psychological distress in antenatal and postnatal periods. The frequency of depressive symptoms increased significantly by about five times from antenatal to postnatal period (based on Edinburg score ≥13, seven people vs. 34 people, P < 0.001). In addition, the frequency of psychological distress increased significantly by about two times from antenatal to postnatal period (based on T score for GSI of BSI-53 ≥63, 13 people vs. 24 people, P < 0.001).

Table 2
Table 2:
Frequency of depressive symptoms and psychological distress in pregnancy and postpartum periods in pregnant women with high-risk pregnancy (n=41)

For testing the first hypothesis, the relationship between EPDS and BSI-53 of the pregnant women in antenatal and postnatal periods is presented in Table 3. The total score of postnatal EDPS correlated significantly with the antenatal depression score of EPDS (r = 0.364). Also, there was a strong positive correlation between antenatal GSI and postnatal GSI (r = 0.670). Further, antenatal GSI of BSI-53 had a significantly positive strong correlation with antenatal EPDS (r = 0.453) and postnatal EPDS (r = 0.701).

Table 3
Table 3:
Correlation between antenatal and postnatal scores of depression, and global severity index of psychiatric symptoms

For testing the second hypothesis, the mean scores of EPDS and BSI-53 of women with complicated pregnancies were compared in antenatal and postnatal periods [Table 4]. The results confirmed that the depression score (EPDS) of women with complicated pregnancies increased significantly from antenatal to postnatal period (7.30 ± 0.80 vs. 25.80 ± 5.80, P ≤ 0.001). Also, all the nine subscales of BSI-53 and GSI of BSI-53 increased significantly from antenatal to postnatal period in women with complicated pregnancies. Moreover, psychological distress significantly increased in the pregnant women from antenatal to postnatal period based on the mean score of GSI-BSI 53 (0.75 ± 0.49 vs. 1.60 ± 0.57).

Table 4
Table 4:
Comparison of mean scores of psychological variables of women in antenatal and postnatal periods

For testing the third hypothesis, we reported the frequency of PTSD in postnatal period. The mean score of PTSD was 1.0 ± 1.09, and the frequency of PTSD symptoms was 12.2% (5/41) based on cut-off PC-PTSD-5 ≥3.


We assessed depressive symptoms and psychological distress of women with high-risk pregnancy from prenatal to postnatal period during COVID-19 pandemic.

The findings revealed that 12.2% of the pregnant women experienced PTSD symptoms in postpartum period during the pandemic. A survey reported psychological distress of PTSD in 33.0% (N = 199) of the general population of Tunisia during the COVID-19 pandemic.[33] While COVID-19 has affected everyone worldwide, the effect of this disease on mental disorders in pregnant women, especially those with complications, remains unknown.[34] Meanwhile, pregnant women would be particularly likely to experience high levels of psychiatric symptoms during the COVID-19 pandemic.[35] A cohort study of COVID-19 reported that pregnant women had higher depressive and anxiety symptoms and PTSD than the pre-COVID-19 cohort.[19]

This study found that both the onset of postnatal depression and persistence of antenatal depression were high in women with high-risk pregnancy followed up in COVID-19. Also, the frequency of depressive symptoms among women with the high risk increased significantly, about five times in postpartum period compared to antenatal period. This is in agreement with previous studies regarding the persistence of depression from antenatal to postnatal period.[3637] A study in Turkey (2015) reported 13.9% prevalence and 49.7% persistence of postnatal depression.[36] Also, a cohort study reported incidence of 20.1% and persistence of 49.6% for depression in the postnatal period.[37] Another study comparing two cohorts of pregnant women (one cohort before and the other after COVID-19) reported that pregnant women in antenatal period had more severe symptoms of depression and anxiety, higher levels of negative affectivity, and lower levels of positive affectivity in the COVID-19 cohort.[19]

There was a possible bias about the prevalence of depressive symptoms in postnatal period. We addressed some potential confounding factors that may be influenced the prevalence of postnatal depression. We used two strategies to control confounders affecting the bias. First, it was probable that women responding to our invitation postpartum were depressed, which may thus overestimate the prevalence of mental symptoms. Thus, we took steps to avoid bias. We checked the mean differences of the prenatal depression scores of EPDS and GSI of BSI-53 between women responding and those not responding to the second survey. Comparing the mean depression score (EPDS) of women responding postpartum with those who did not respond to the second survey confirmed no differences between the two groups (7.33 ± 4.80 vs. 7.98 ± 5.10, P = 0.602). Also, there was no significant difference in the mean GSI score of BSI-53 between women responding postpartum and those who did not respond to the second survey (0.75 ± 0.45 vs. 0.61 ± 0.85, P = 0.633). The second confounder was experiencing stressful events for women between the first phase of assessment and the second phase of the study in postnatal period. We excluded women experiencing stressful events between the first and second phases of assessment, such as death of a loved one, loss of job, loss of fetus, and traumatic birth. However, there were other confounders related to depression that we could not control, such as marital conflict, job conflict, and family income problems.

Limitations and implications of the study

The current study’s findings indicated that psychological distress in antenatal period was almost twice as that in postnatal period in women with a complicated pregnancy. In line with our results, some studies reported an association between prenatal and postnatal psychological problems with prenatal problems and birth outcomes.[3839] However, the psychological distress rate was lower in other studies than in our study in postpartum period during the COVID-19 pandemic.[4041]

The higher prevalence of depressive symptoms and psychological distress in our study compared to previous reports may be due to some reasons. First, the population in this study consisted of women with high-risk pregnancy. Evidence supports that women with high-risk pregnancy experience more serious psychological problems than those with low-risk pregnancy.[18] Second, we assessed psychological problems in pregnant women during the acute phase of the COVID-19 pandemic. The COVID-19 pandemic affected the routine healthcare of our patients in postpartum period. In the first acute phase of the pandemic, clinic appointments were limited in public maternity settings. Also, many obstetricians canceled their scheduled visits with women in pregnancy or postpartum period.

The present study had several limitations. The number of participants was small in postnatal period. Although the present study’s design was prospective, the follow-up of the patients was done during the acute phase of the COVID-19 pandemic, and we could not provide efficient postpartum management for our patients in the hospital. Our hospital was a COVID-19 treatment center for 3 months, from February to May 2020. Thus, we had to follow our patients through an online survey. The loss of about 80 pregnant women in the prospective phase was the main limitation of the study. Also, the effect of the stress of COVID-19 on mental disorders in postpartum period was another limitation. This study could not determine to what extent the mental symptoms of pregnant women in postnatal period were due to COVID-19. Further research should be planned to assess the effect of COVID-19 on postnatal mental disorders. We also changed the assessment method of outcomes from filling in the questionnaires at the clinic to conducting an online survey, which could affect the results.

Although we do not precisely know how the threat of COVID-19 aggravates psychological problems in postnatal period, our results emphasize that screening mental problems for women with high-risk pregnancy is critical during the COVID-19 pandemic for postnatal visits. We recommend that all maternity care providers use a screening assessment tool to detect women at risk of psychological distress, especially those with high-risk pregnancy, during prenatal and postpartum visits.


The study demonstrated that COVID-19 might aggravate the prevalence and persistence of postnatal depression in women with a high-risk pregnancy. Further exploration is required to understand how COVID-19 affects postpartum care and psychological problems. Future research should also assess the benefits of specific mental care during the COVID-19 pandemic to prevent psychological distress. Moreover, the potential long-term negative consequences of this crisis should be addressed in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Coronavirus disease 2019; depression; pregnancy

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