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e ISSN: 2645-9248 Journal homepage: www.jidhealth.com Open Access
Investigating of fear of COVID-19 after pregnancy and association
with breastfeeding
Asiye Uzun1*, Güzin Zeren Öztürk 2, Zeliha Bozkurt 2, Mehmet Çavuşoğlu 2
Abstract
Background: COVID-19 pandemic has certainly become the most important global problem. Deficient information
may increase the fear of COVID-19, affect pregnant women's psychology, and even affect breastfeeding during the
postpartum period. This study aimed to assess the fear of the COVID-19 pandemic after pregnancy and its association
with breastfeeding.
Methods: A cross-sectional study designed to survey all pregnant women who gave birth at ≥36 weeks between
March 10 and June 10, 2020, at the Private Nisa Hospital, Istanbul, Turkey. Participants respond to questions related
to sociodemographic, genealogical, pregnancy, birth information, postpartum baby care, and breastfeeding status, in
addition to the 7-item Fear of COVID-19 Scale (fcv-19s) via phone. Descriptive, bivariate, and linear regression
analysis was performed to predict fcv-19s. SPSS version 22.0 was used to analyze the data.
Results: A total of 906 (response rate 78.8%) respondents with a mean age of 29.59 (±4.74years) were included in
the study. Most of them were highly educated (75.2%), housewives(86.1%), and living in nuclear families (96.1%). The
majority of women (92.9%) gave birth at 38 weeks via cesarean section (71.7%) and breastfeeding (94.2%). Although
the mean score of fcv-19s was high in non-breastfeeding mothers, no significant correlation was seen in bivariate
analysis. In the linear regression analysis, the highly educated, good income status, having at least once follow-up a
month, having a history of psychiatric disease, cesarean section delivery, competence in baby care, breastfeeding,
and milk adequacy significantly predicted the (fcv-19s) (R = 0.67, R2 = 0.46, F = 42.10, p < 0.001).
Conclusion: During pandemics, including COVID-19, the psychological state of society is negatively affected, and
therefore special attention must be given to the most affected groups, especially pregnant and postpartum women.
Keywords: SARS-CoV-2, Pandemics, Breastfeeding, Pregnancy, Fear of COVID-19, Istanbul, Turkey
Background
After its appearance in China, the COVID-19 pandemic soon
affected the whole world [1]. The first case of COVID-19 in
Turkey was detected on 11th March 2020 [2]. As of June 26,
2020, the total number of cases in Turkey was 194,511, while
167,198 patients have been treated, and 2.6% of the cases have
died [3]. A global health and economic crisis, the COVID-19
pandemic has affected various aspects of life. The world was
not ready to face such a crisis [4]. Factors such as worldwide
mortality rates or constant exposure to pandemic-related news
and social isolation cause individuals to live with fear and
anxiety [5]. Especially for pregnant women who are in a
psychologically sensitive period. As with many infections,
pregnant women are in the risk group for COVID-19. A study
showed that pregnant or postpartum women of the same age
might have more intensive care requirements than nonpregnant
women [6,7]. Although no data exist on the transplacental
transmission of COVID-19 in infantile terms, the viruses were
not detected in the amniotic fluid, umbilical cord blood, or
placental tissue [8,9], several cases of infected newborns have
been reported in a recent study [10]. Nevertheless, it remains
unclear if these newborns were infected before, during, or after
birth and in what ways they were infected [10]. Furthermore,
there is no data on whether the infants can get infected through
breast milk after childbirth or not [11]. The World Health
Organization (WHO) considered it safe to breastfeed during the
COVID-19 pandemic [12]. Additionally, limited information,
lack of treatment and vaccines, and changing the daily number
of cases may increase the prevalence of mental disorders,
including the fear of COVID-19 among pregnant women [13].
The impact of mothers' psychological problems can extend to
disrupt the relationship between the mothers and their babies
and even affect breastfeeding [14]. Therefore, the present study
is intended to investigate the fear of COVID-19 and the related
factors among a sample of Turkish pregnant women in Istanbul
City.
___________________________________________________
asiye.uzun@nisahastanesi.com
1Department of Obstetrics and Gynecology, Medipol Teaching and Research
Hospital, Istanbul, Turkey
Full list of author information is available at the end of the article
Uzun A, et al., Journal of Ideas in Health (2021); 4(1):227-333 328
Methods
Study population and sample
A cross-sectional phone-based study designed to survey
pregnant women attending the private “Nisa Hospital” in
Istanbul city, Turkey. The study was conducted during the
periods between March 10 and June 10, 2020.
Inclusion and exclusion criteria
At the time of the study, all pregnant women who gave birth at
≥36 weeks were included. However, postpartum with a history
of depression, chronic disease, multiple pregnancies, bad
hemodynamics during the postpartum period, and mothers of
infants with a low “Apgar Score” or those who needed
resuscitation during the postpartum period were not included in
the study.
The sampling technique
Considering the COVID-19 pandemic and the subsequent
lockdown and social distancing, the patients were contacted
personally through their registered phone at the hospital, and
verbal consent was obtained from each patient willing to
participate. The total number of pregnant women giving birth in
this period was 1500; however, 1150 women met the study’s
inclusion criteria.
Independent variable
Education was categorized into low educated (under the high
school) and high educated (above the high school).
Employment is defined as either “employed or housewife”. The
monthly income of 4400 TL is used as the cut-off point of low
and high-income status. The exchange rate on 1st March 2020
was USD 1= TR 7.8. A family with two members is defined as
a "nuclear family", and those exceeding two members are
named "large families". The response to questions “having a
history of psychiatric disease or a family member with a history
of the psychiatric disease” was recorded into “Yes” or “No”.
Dependent variable
The 7-item (5-point Likert scale) valid and reliable Turkish
version of fcv-19s was recruited to collect the data [15]. The
original version of fcv-19s was developed by Ahorsu et al. [16].
The total score was calculated by adding each item score (from
7 to 35). The higher the score, the greater the fear of COVID-
19.
Data collection tools
The survey includes an information form of 15 items regarding
sociodemographic characteristics (age, educational background,
and working status), pregnancy birth information (risky
pregnancy status, the form of birth, and the week of birth), baby
care, and nutrition information (breastfeeding, competence in
care, and getting help) in three parts, and the questions of the
Turkish version of the Fear of COVID-19 Scale (fcv-19s).
Statistical analysis
All statistical analyzes were performed using IBM SPSS
version 22.0 (SPSS Inc., Chicago, Illinois, USA). Continuous
variables are presented as Mean ± SD, and categorical variables
are presented as numbers and percentages. Comparisons
between groups were made using the Mann Whitney-U test for
continuous variables. Spearman correlation analysis was used
for the correlation relationship of continuous variables. Finally,
linear regression analysis was performed to compare the Covid-
19 fear Scale and the related variables. A P-value of <0.05 was
considered statistically significant.
Results
Characteristics of the participants
Out of 1150 eligible women, 906 were included in the study
(response rate 60.4%). The mean age was 29.59 (±4.74 years).
Most of the respondents were high educated (75.2%),
housewives (86.1%), nuclear family (96.1%), and low-income
(≤4400 TL) families (53.9%). Most of the respondents neither
having a history of psychiatric disease (95.9%) nor having a
family member with a history of psychiatric disease (87.3%).
Table 1 Sociodemographic, personal, and genealogical
characteristics of the participants
Variables
N (%)
Educational Background
Lower than high school
225 (24.8)
High school and higher degree
681 (75.2)
Employment
Employed
126 (13.9)
Housewife
780 (86.1)
Income Status
Low (≤4400 TL)
488 (53.9)
High (>4400 TL)
418 (46.1)
Family Type
Large family
35 (3.9)
Nuclear family
871 (96.1)
Having History of Psychiatric Disease
No
869 (95.9)
Yes
37 (4.1)
Having a Family Member with History of
Psychiatric Disease
No
791 (87.3)
Yes
115 (12.7)
Pregnancy and birth information of the participants
The details concerning the pregnancy and birth of the
participants are provided in Table 2. The mean number of the
participants' pregnancies was 1.89 ±1.03; the mean number of
follow-up during pregnancy was 11.11 ±2.96. Most women
made a planned (96.1%) but not risky pregnancies (82.7%),
equal to or more than 38 weeks deliveries (92.9%) by cesarean
section (C/S) procedure (71.7%).
Table 2 Pregnancy and birth information of the participants
Demographic variables
Categories
N (%)
Planned Pregnancy
No
57 (6.3)
Yes
849(96.1)
Risky Pregnancy
No
749(82.7)
Yes
157(17.3)
Birth Week
36–38
64(7.1)
≥38
842(92.9)
Form of Birth
NSD*
256(28.3)
C/S*
650(71.7)
* NSD=Normal Spontaneous Delivery, C/S= Cesarean Section
Postpartum baby care and breastfeeding status
In Table 3, postpartum baby care and breastfeeding status were
given. The majority of respondents were breastfeeding mothers
(94.2%). About seventy percent thought that milk is not
Uzun A, et al., Journal of Ideas in Health (2021); 4(1):227-333 329
enough; however, one-third (34.3%) used feeding formula.
Most women (91.2%) felt components in baby care; however,
51.1% declared that they have an assistant for bay care. Most of
the women (98.1%) showed interest in the newborn monitoring
and taking the infant to vaccination; however, few have doubts
about the vaccine and fear catching an infection.
Table 3 Postpartum baby care and breastfeeding status
Demographic variables
Category
N (%)
Feeling competent in baby care.
No
80(8.8)
Yes
826(91.2)
Having an assistant for baby care
No
262(28.9)
Yes
644(51.1)
Breastfeeding status
No
53(5.8)
Yes
853(94.2)
Thinking that milk is not enough
No
268(29.6)
Yes
638(70.4)
Feeding formula
No
595(65.7)
Yes
311(34.3)
Newborn monitoring/vaccination
status
No
17(1.9)
Yes
889(98.1)
Newborn monitoring/reasons for
not taking the infant to vaccination
Doubts about vaccine
5(30)
Fear of catching an infection
5(30)
Other
7(40)
The Spearman correlation test was performed to correlate
between the fcv-19s survey score and the continuous dependent
variables. A statistically significant correlation was found
between the number of pregnancies (Rho=−0.183, p<0.001) and
the number of follow-ups (Rho=0.307, p<0.001) with the total
fcv-19s survey score. However, there was no statistically
significant correlation between respondents' age and the total
fcv-19s survey score (rho=−0.014, p=0.664) (Table 4).
Relationship between fcv-19s survey score and the
independent variables
The mean score of the fcv-19s scale was (16.90 ±4.80, range:7-
30). In table 5, the Mann–Whitney U test was used to compare
the mean between variables in the bivariate analysis. There was
a statistically significant difference between the fcv-19s survey
score and most of the independent variables. The high educated
(P<0.001), employed (P =0.008), income 4400TL or less,
nuclear family (P =0.015), non-planned pregnancy (P =0.007),
risky pregnancy (P =0.011), having a history of psychiatric
disease (P <0.001), having a family member with a history of
psychiatric disease (P<0.001), feeling not competent in baby
care (P <0.001), underwent C/S (P <0.001), having an assistant
for baby care (P =0.022), thinking that milk is not enough
(p=0.028), feeding with a formula (P =0.006) and fear of
COVID-19 (P <0.001) having higher fcv-19s survey score than
their counterparts.
The linear regression analysis between FCV-19S survey
score and the variables
The independent variables have significantly predicted the
COVID-19 Fear Scale (R = 0.67, R2 = 0.46, F = 42.10, p <
0.001) in the linear regression analysis. These significant
variables describe approximately 46% of the total variance.
Regression analysis showed that higher educated (P-value =
0.022, <0.05), high income (P-value = 0.018, <0.05), increased
number of follow up (P-value= p<0.001, <0.05), having history
of psychiatric disease (P-value= 0.005, <0.05), positive family
member with a history of psychiatric disease (P-value= 0.000,
<0.05), gave birth by C/S (P-value= 0.001, <0.05), incompetent
in baby care (P-value= 0.001, <0.05), breastfeeding(P-value=
0.001, <0.05), adequate lactation (P-value= 0.015, <0.05),
feeding formula (P-value= 0.014, <0.05), and those who had a
fear of COVID-19 (P-value= p<0.001, <0.05) were significantly
associated with increased of the fcv-19s score.
Discussion
Pregnancy, childbirth, postpartum, and the adaptation period
where mothers get used to their baby are the most sensitive
times for women physically and spiritually. Therefore, there
may be a risk of predisposition to psychological disorders. The
negativity and uncertainty brought by the COVID-19 pandemic
increased people's fear and anxiety [17]. Similarly, in our study,
women who fear COVID-19 expressed the highest fcv-19s
survey scores. The high scores of the fcv-19s survey in
individuals with psychological disorders and a family member
with psychological disorders may be due to these individuals'
high susceptibility to psychological problems. Previous studies
showed that many psychological disorders might have a genetic
predisposition, and there is a high probability of recurrence
[18,19]. In our study, the fcv-19s survey score was also high
among the highly educated, good income, and employed
mothers. These are interrelated socio-economic variables.
Several studies have shown a positive correlation between the
level of education and COVID-19 awareness [20-22].
Awareness can increase the fear of an outbreak that has not yet
been cured and vaccinated. The negative economic impacts of
the COVID-19 pandemic can also be the reason for increased
fcv-19s survey scores in working individuals [23]. The low fcv-
19s survey scores among the individuals with planned and risk-
free pregnancies may be related to the mothers' feeling
emotionally healthy and ready. Previous studies showed a high
rate of postpartum depression in mothers who do not have
planned pregnancies or have risky pregnancies [24,25]. In our
study, the reason behind the high fcv-19s survey scores among
women who gave birth by C/S may be explained by the fear of
giving birth by surgery and longer hospitalization, which might
result in being infected by the coronavirus.
Table 4 Correlation analysis results for the relationship between COVID-19 scale scores and some variables
Variables
Age
Number of pregnancy
Number of those following
Measure of COVID-19
Age
r
1
Number of pregnancy
r
0.488**
1
p
<0.001
Number of follow up
r
-0.026
-0.362**
1
p
0.443
<0.001
The measure of COVID 19
r
-0.014
-0.183**
0.307**
1
p
0.664
<0.001
<0.001
Table 5 Relationship between fcv-19s survey score and the independent variables (n=906)
Uzun A, et al., Journal of Ideas in Health (2021); 4(1):227-333 330
Table 6 Results of the linear regression analysis between fcv-19s survey score and the independent variables (n=906)
B
SE
Beta
t
P-value
95% CL Lower-Upper
Age
0.008
0.031
0.008
0.260
0.795
-0.05,0.06
(High educated (VS low educated)
0.743
0.323
0.067
2.301
0.022
0.11,1.37
Housewife (VS employed)
-0.053
0.365
-0.004
-0.144
0.886
-0.77,0.66
High income (VS low income)
0.618
0.261
0.064
2.371
0.018
0.10,1.13
A large family (VS Nuclear family)
0.821
0.643
0.033
1.276
0.202
-0.44,2.08
Multipara (VS Primipara)
0.168
0.152
0.036
1.104
0.270
-0.13,0.46
Planned Pregnancy (VS not planned)
-0.915
0.554
-0.046
-1.652
0.099
-2.00,0.17
Increased number of follow-up (VS No)
0.230
0.047
0.142
4.932
0.000
0.13,0.32
Risky Pregnancy (VS No)
-0.328
0.345
-0.026
-0.953
0.341
-1.00,0.34
Having History of Psychiatric Disease (VS No)
1.822
0.648
0.075
2.810
0.005
0.55,3.09
History of psychiatric disease in the family (VS No)
2.577
0.410
0.179
6.289
0.000
1.77,3.38
C/S (VS NSD)
2.434
0.308
0.228
7.902
0.000
1.82,3.03
Feeling Incompetent in Baby Care (VS Competent)
-2.078
0.450
-0.123
-4.624
0.000
-2.96, -1.19
Having an Assistant for Baby Care (VS No)
-0.153
0.274
-0.014
-0.557
0.578
-0.69,0.38
Breastfeeding (VS No)
1.994
0.576
0.097
3.459
0.001
0.86,3.12
Thinking that Milk is Enough (VS No)
1.395
0.571
0.133
2.441
0.015
0.27,2.51
Feeding Formula (VS No)
1.409
0.575
0.139
2.452
0.014
0.28,2.53
A decrease in the fcv-19s survey scores was determined as the
number of pregnancies increased in our study. The reason may relate to mother's previous knowledge and experience. Lack of
knowledge and inexperience among mothers cause a feeling of
fcv-19s total Score
N
Mean ±SD
P-value
Educational Background
Low educated
High educated
225
681
15.07±4.72
17.51±4.67
<0.001
Employment
Employed
Housewife
126
780
17.97±4.26
16.73±4.85
0.008
Income status
Low (≤4400 TL)
High (>4400 TL)
488
418
16.44±4.60
17.44±4.98
0.004
Family type
Large family
Nuclear family
35
871
15.00±4.68
16.98±4.79
0.015
Planned pregnancy
No
Yes
57
849
18.72±4.49
16.78±4.80
0.007
Risky pregnancy
No
Yes
749
157
16.70±4.37
17.85±5.01
0.011
Having a history of psychiatric disease
No
Yes
869
37th
16.70±4.69
21.65±4.92
<0.001
Having a family member with a history of psychiatric disease
No
Yes
791
115
16.33±4.63
20.84±4.03
<0.001
Birth Week
Preterm
Term
64
842
11.75±5.68
16.84±4.72
0.296
Feeling competent in Baby Care.
No
Yes
80
826
20.56±4.13
16.55±4.71
<0.001
Form of birth
NSD
C/S
256
650
13.80±4.27
18.12±4.40
<0.001
Having an assistant for baby care
No
Yes
262
644
16.35±5.07
17.13±4.67
0.022
Breastfeeding status
No
Yes
53
853
16.96±4.9
16.02±1.81
0.082
Thinking that milk is enough
No
Yes
268
638
17.49±4.72
16.66±4.81
0.028
Feeding with formula
No
Yes
595
311
16.56±4.86
17.56±4.62
0.006
Fear of COVID-19
No
Yes
161
745
11.84±3.57
18.00±4.30
<0.001
Newborn Monitoring/Vaccination status
No
Yes
17th
889
17.59±4.66
16.89±4.80
0.493
Uzun A, et al., Journal of Ideas in Health (2021); 4(1):227-333 331
incompetence to care for the baby [26]. Moreover, the present
study showed that women who feel inadequate in baby care had
high fcv-19s survey scores.
In 2005, 74.2% of US infants were breastfed at least once
after delivery, but only 31.5% were exclusively breastfed at the
age of 3 months [27]. According to Turkey's Population and
Health Research 2013 data, only 57.9% of babies were
breastfed in the first two months of life [28]. In our study, the
continuation rate of breastfeeding was 94.6%. However, the rate
of the “only-breastfed infants” accounted for 65.5%. We think
that the high proportions are due to the characteristics of the
surveyed sample. Peregrin T [29] emphasized that the main
cause of inadequate breastfeeding is a lack of knowledge about
breastfeeding. Furthermore, Swanson and Kevin [30] indicated
that nursing and family support are also important and training
programs for breastfeeding education and support. Likewise,
the less fear among mothers living in a large family in our study
may be due to the fact that they received support from other
family members during the postpartum period. At this point, we
believe that displaying videos about COVID-19, breastfeeding
and baby care, and useful practices to mothers during
hospitalization before or after childbirth will significantly
reduce the fear of COVID-19 and positively inform the mother
regarding breastfeeding and baby care. Although there was no
significant correlation, the fcv-19s survey scores were higher
among non-breastfeeding mothers than their counterparts.
However, the regression analysis correlation with other factors
indicates that the fcv-19s survey score can disrupt breastfeeding
when combined with other risk factors. For example, in the
postpartum period, it is necessary to take a holistic evaluation.
Otherwise, postpartum negative effects may disrupt
breastfeeding [31]. Additionally, anxiety, stress, and fear
sometimes make breastfeeding inefficient and can often lead to
its interruption [32,33]. We know that breastfeeding is more
than a choice and is the most important investment in the future
for both mother and baby [34]. It is believed that, beyond its
benefits and health investments that are not limited to the actual
breastfeeding period, it has long-term effects on long-term
quality of life and strengthens the immune system [35]. The
WHO recommends extending this precious process up to 2
years, not only six months [36,37]. Supporting breastfeeding,
which is important for generations, is important for individual
and community health [38]. Our study's limitations are the
inability to evaluate observational symptoms due to the survey
via phone call. Organizing prenatal and postnatal training to
reduce the fear of COVID-19 will positively affect both the
psychological state of the mother and breastfeeding. Besides,
individuals who are at risk of high fear, especially those who
have a history of psychological disorders and a family member
with a history of psychological disorders, should be intervened
through online support programs, if necessary. Our study's
clinical results are of significance since they identify the issues
that should be considered to provide nursing support to mothers
during this process and establish strategies for reducing
breastfeeding discontinuation during the COVID-19 pandemic
period.
Conclusion
It is concluded that during the COVID-19 pandemic, COVID-
19 fear and related factors combined affect breastfeeding among
mothers. We believe that mothers' holistic evaluation in this
period and conducting awareness-raising works are necessary to
reduce the psychological burden created by the COVID-19
pandemic. Integrating the issues related to the COVID-19
pandemic into educational materials used in pregnancy,
childbirth, and the postpartum period will yield an increased
level of knowledge about corvid-19. This will positively affect
the relationship between mother and baby as well as
breastfeeding, which will reduce anxiety and postpartum
psychological load.
Abbreviation
COVID-19: Coronavirus Disease-19; WHO :World Health
Organization; fcv-19s :Fear of COVID-19 Scale; NSD: Normal
Spontaneous Delivery; C/S: Cesarean Section
Declaration
Acknowledgment
We would like to thank Mrs. Melisa Naz for his great efforts in
helping to prepare the questionnaires and the necessary links and
distribution through the social networking sites. We also extend our
thanks to all respondent to the survey during the Coronavirus
pandemic.
Funding
The author received no financial support for the research, authorship,
and/or publication of this article.
Availability of data and materials
Data will be available by emailing asiye.uzun@nisahastanesi.com
Authors’ contributions
Authors are equally participated in the concept, design, writing,
reviewing, editing, and approving the manuscript in its final form. All
authors have read and approved the final manuscript.
Ethics approval and consent to participate
We conducted the research following the Declaration of
Helsinki, and the protocol was approved by the Non-Interventional
Ethics Committee of Medipol University Faculty of Medicine, Istanbul,
Turkey by Decision Number 31 on 07/23/2020.
Consent for publication
Not applicable
Competing interest
The authors declare that they have no competing interests.
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Author details
Uzun A, et al., Journal of Ideas in Health (2021); 4(1):227-333 332
1Department of Obstetrics and Gynecology, Medipol Teaching and
Research Hospital, Istanbul, Turkey. 2Department of Family Medıcıne
Şişli Etfal Training and Research Hospital İstanbul, Turkey.
Article Info
Received: 07 January 2021
Accepted: 03 February 2021
Published: 22 March 2021
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