COVID-19 and Obstetrical Care: Coping With New Stress

Objective Our study aimed to assess the mental health outcomes and coping strategies among healthcare workers (HCWs) in an already over-burdened maternity ward and labour room during the coronavirus disease 2019 (COVID-19) pandemic. Methods This cross-sectional questionnaire survey was conducted using Google Forms (Google LLC, Mountain View, CA), which included demographic characteristics, perceived stressors, and validated scales: the Depression, Anxiety and Stress Scale - 21 Items (DASS-21), Insomnia Severity Index, and the Brief Coping Orientation to Problems Experienced (Brief COPE) scale. The results were evaluated and compared among COVID-19 caregivers and other HCWs. Results A total of 184 participants were included in the study, out of which 112 (60.9%) were COVID-19 caregivers. Overall, HCWs managing COVID-19 patients experienced significantly higher levels of depression, anxiety, and stress. They often adopted an avoidant coping style (p-value: 0.006). The results of binary logistic regression analysis revealed that living with family and perceiving multiple stressors appeared to be associated with increased risk of anxiety while being a COVID-19 caregiver and appeared to be a risk factor for stress. Avoidant coping was found to be associated with insomnia while approach coping was less associated with anxiety. The most prevalent stressor among HCWs at our institute was distancing from family and friends (62%) followed by fear of getting infected (51.1%). Compared to other HCWs, the stressors perceived in significantly higher proportion by COVID-19 caregivers included distancing from family and friends (p-value: 0.003), scarcity of workforce (p-value: 0.005), and dealing with non-cooperative patients (p-value: <0.001). Conclusion We would request the immediate attention of the concerned authorities to implement interventions to buffer the impact of COVID-19 in the already stressed-out maternity wards and labour rooms.


Introduction
The World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) outbreak a pandemic on March 11, 2020, and there has been a significant rise in infections among both the general public and healthcare workers (HCWs) since then [1][2][3]. The specialties like obstetrics and gynaecology are managing COVID-19 pregnancies by only limited evidence-based protocols [4]. In general, outpatient care has been put on hold by other specialties, but such an approach is not feasible in obstetrics. The already understaffed maternity wards are facing additional problems such as a rapidly changing environment, unsafe workplace, and rapidly changing employee shift patterns [5][6][7][8]. With the increasing number of COVID-19 pregnancies, HCWs in maternity wards and labour rooms continue to take additional risks in order to manage the crisis. The objective of our study is to evaluate mental health outcomes and the strategies used to deal with them by HCWs and to identify the perceived stressors among HCWs and to compare the results among HCWs working in COVID-19 and non-COVID-19 wards. The Department of Obstetrics and comprised seven questions from the validated Insomnia Severity Index [8,9] to assess any impact on sleep; the permission to use this method was obtained. The fourth section contained a single question with multiple choices to choose among the various possible stressors. The fifth section contained 28 questions from a validated, standardized Brief Coping Orientation to Problems Experienced (Brief COPE) inventory [10] to examine the coping strategies employed by HCWS in response to the COVID-19 pandemic.

Procedure
The questionnaire survey was done using the online web tool (Google Forms; Google LLC, Mountain View, CA). The link was circulated on official obstetrics and gynaecology WhatsApp (Facebook, Inc., Menlo Park, CA) groups of HCWs at the study institute and was kept open for 21 days. Three reminders at intervals of six days were sent out for filling up the same. The questionnaire began with a section on informed consent where the respondent was given the option to opt out of the survey at any time. Confidentiality and anonymity of the respondents were ensured. All completely filled responses received within 21 days were included in the study and analyzed. The results among COVID-19 caregivers and other HCWs were compared with respect to the magnitude and type of mental health outcomes, perceived stressors, and coping strategies being implemented on individual levels.

Data management
The data was imported to a Microsft Excel (Microsoft Corporation, Redmond, WA) spreadsheet, and the analysis was done using SPSS Statistics version 21.0 (IBM, Armonk, NY). Categorical variables were presented in numbers and percentages (%), and continuous variables were presented as means ± SD and median with interquartile ranges. The normality of data was tested with the Kolmogorov-Smirnov test. If the normality was rejected, then a non-parametric test was used. Statistical tests were applied as follows: 1. Quantitative variables were compared using the Mann-Whitney test/Kruskal-Wallis test (as the data sets were not normally distributed) between the groups.
2. Qualitative and categorical variables were compared using the chi-square test.
3. Binary logistic regression (stepwise backward LR) was used to determine the adjusted estimates.
A p-value of <0.05 was considered statistically significant.

Results
A total of 184 HCWs responded to the survey and filled the questionnaire. The response rate was 71.8% (184/256).

Mental health outcomes
The mental health outcomes of the respondents are summarized in Table 2 and Table 3 . Also, all levels (mild, moderate, and severe) of depression, anxiety, and insomnia were significantly higher among COVID-19 caregivers ( Table 2). Overall, sleep disorders were significantly higher among young HCWs (p-value: 0.049); females were significantly more stressed out (p-value: 0.007) and depression was significantly more among HCWs living with their families (p-value: 0.032) ( Table 3).    Although there was no significant difference in approach coping scores between the two groups, informational coping was significantly higher among the COVID-19 caregivers (p-value: 0.002). Also, humour approach scores were higher among COVID-19 caregivers (p-value: 0.036) ( Table 5).

Risk factor analysis for mental health outcomes
The results of binary logistic regression analysis, after adjusting for confounders, revealed that living with family and perceiving multiple stressors appeared to be associated with increased risk of anxiety [adjusted odds ratio (

Discussion
The response rate of our study was 71.8%, which in other studies varied from 30% to 94% [1][2][3][9][10][11]. Out of 184 respondents in our study, 60.9% were COVID-19 caregivers while it was just 41.5% in a study by Lai et al. [1]. Similar to many other published studies, our study had more young workers, more HCWs living alone, and more nursing staff. This may be attributed to the conscious administrative decision to exclude vulnerable people (older and those with significant comorbidities) from direct COVID-19 care [1,3,[9][10][11][12][13].
A study assessing mental health outcomes during the COVID-19 pandemic among obstetricians and gynaecologists concluded that they experience significantly higher rates of both major depressive disorder and generalized anxiety disorder compared to the UK-nationwide estimates. The subgroup analysis showed that anxiety was more common among female doctors compared to males [4]. Uzun et al. also found poorer mental health in COVID-19 employees in the obstetrics and gynaecology department [5]. We found depression, anxiety, stress, and insomnia in 20.7%, 28 HCWs positive for depression, anxiety, insomnia, and distress respectively, which is much higher than what we found in our study [1]. These higher percentages may be due to the fact that China was the first country to be hit by this pandemic and a lack of preparedness to deal with this unknown novel virus would have played a significant role in causing distress to HCWs. Chatterjee et al. found depression, anxiety, and stress in 34.9%, 39.5%, and 32.9% of doctors respectively in the early phase of the pandemic in India [14,15]. The percentage of same was lower in our study, which might be due to better preparedness at our institute: multiple training sessions, adequate availability of personal protective equipment (PPE), better lodging and dining facilities, and the government's decision to provide insurance to COVID-19 workers. On the contrary, Tan et al. reported a much lesser prevalence of depression (8.1%), anxiety (20.7%), and stress (6.4%) in their study from Singapore, which may reflect their extremely wellorganized healthcare system, adequate preparations to deal with the pandemic, and timely information sharing along with other employee-centric measures to protect them from any health hazard [3].
In the pre-COVID-19 era also, many studies found a higher incidence of depression, stress, and burn-out among HCWs dealing with emergencies [16,17]. Ghetti et al. found that obstetrics and gynaecology residents are more prone to stress and burn-out, thereby affecting patient care. So, they were offered Balint training for 12 months, which enhanced their confidence by improving their psychological outlook and interest in patient care [18]. Thakrar et al. also observed poor mental health among HCWs in emergency departments [19]. A cross-sectional multicentre study conducted in eight cities in Iran on obstetrics and gynaecology specialists managing pregnant patients infected with COVID-19 showed significantly higher scores on a questionnaire evaluating depression as compared to other healthcare practitioners. Depression affected their quality of life too. This study also reported that social support improved some domains of quality of life like physical functioning, energy/fatigue, and emotional well-being [20].
We also found a significantly higher prevalence of all levels of depression, anxiety, and stress as well as insomnia among COVID-19 caregivers in our department, which is consistent with other studies [1,4,5,[9][10][11][12]13,15]. From our findings, we presume that COVID-19 HCWs in other emergency departments are also highly susceptible to all psychiatric symptoms during the ongoing COVID 19 pandemic.
The adjusted analysis in our study showed that living with family appeared to be associated with increased risk of anxiety, which can be attributed to the associated apprehension of carrying the infection to home; while being married was associated with a lower risk of stress, which can be explained by the availability of support system to deal with stress. It has been suggested that remaining connected to family members through video calls acts as a major stress buster. Lack of family support and being unmarried have shown an association with depression, anxiety, and distress in studies from China. These studies also inferred that social support reduces anxiety and stress and improves sleep quality among COVID-19 HCWs [9-10,21]. Shah et al. found that the most significant stressor among obstetricians was associated with being up-to-date with rapidly changing guidelines, pathways, and protocols related to COVID-19 practice [4]. However, thanks to multiple training sessions at our institute, we did not face this problem. In other studies, the fear of transmitting infection and getting infected topped the list of stressors, followed by PPE shortage and isolation from family [1,2,9,22]. At our institute, thanks to the adequate supply of seemingly good-quality PPE, this was the least reported stressor experienced by the HCWs.
There are not many studies that have evaluated coping strategies among HCWs involved in COVID-19 care.
Our study attempts to do so and we found that young HCWs (<30 years), nurses, and COVID-19 caregivers had significantly higher avoidant coping scores compared to non-COVID-19 HCWs. Emre Umucu et al. have demonstrated a positive association of COVID-19-related perceived stress with coping strategies: denial, substance use, behavioural disengagement, venting, religion, and self-blame. Our study revealed similar findings [21].
Studies have reported that the kind of coping style can determine the occurrence of psychological distress. Practising a negative coping style leads to substandard mental health with long-term consequences [23]. Koinis et al. reported that symptoms of stress and depression decrease with a positive approach while they increase with avoidant coping [24]. Eisenberg et al. have suggested that avoidant coping is not preferable to manage anxiety while approach coping results in devising better responses to deal with the adversity [25].
Another study suggests that employment of predominantly avoidant coping strategies leads to poorer quality of life and increased frequency of depression [26]. The number of perceived stressors and the use of avoidant coping strategies are positively correlated with all grades of depression, anxiety, and stress [27]. A prospective study by Holahan et al. including 1,211 middle-aged men and women reported that avoidant coping leads to both chronic and acute life stressors after four years and depressive symptoms after 10 years. In our study, avoidant coping was found to be associated with increased insomnia. Other studies on dementia caregivers and adolescents also endorse this finding [28][29][30].