121 JNK JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk Factors Triggering Anxiety for Pregnant Women during the Covid 19 Pandemic Triatmi Andri Yanuarini1, Shinta Kristianti2, Finta Isti Kundarti3 Moh. Ali Mansur4, Sumy Dwi Antono5 1,2,3Department of Midwifery, Poltekkes Kemenkes Malang, Indonesia Article Information Abstract Covid-19 infection is more common in expectant mothers. than people who are not expecting. This causes pregnant women to experience anxiety and even depression if they are not treated immediately. The pandemic caused by COVID-19 can psychologically cause increased levels of tension and anxiety brought on by worry about spreading disease and its effects. The objective of the study was to identify the triggering factors for anxiety in during the Covid-19 epidemic, expectant mothers. The design of the study was cross-sectional research design. The sample included several expecting mothers in Mojoroto District, Kediri City as many as 67 respondents. The data collection used questionnaire. The data analysis used ordinal regression. The results showed the p-value of pregnancy complications (0.034), limited food ingredients (0.047), history of depression (0.000), environment (0.001), loss of caregiver (0.000) which meant these variables affected the occurrence of anxiety during the Covid-19 epidemic in expecting mothers. COVID-19 increased the risk of complications in expecting mothers, besides that social restrictions also caused limited food ingredients, difficulty getting caregivers. This caused pregnant women to experience depression. The covid pandemic had also caused many deaths and generating worry in expectant mothers. The conclusion is that the triggering factors for pregnancy-related stress and the Covid-19 epidemic pregnancy complications, limited food ingredients, a history of depression, anxiety about the environment and anxiety about losing a caregiver. History Article: Received, 14/03/2023 Accepted, 25/04/2023 Published, 30/04/2023 Keywords: covid-19, anxiety factors, pregnant women © 2023 Journal of Ners and Midwifery Correspondence Address: Poltekkes Kemenkes Malang – East Java, Indonesia P-ISSN : 2355-052X Email : fintaistikundarti@gmail.com E-ISSN : 2548-3811 DOI: https://doi.org/10.26699/jnk.v10i1.ART.p121-130 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) http://jnk.phb.ac.id/index.php/jnk mailto:fintaistikundarti@gmail.com https://doi.org/10.26699/jnk.v10i1.ART.p121-130 122 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 121-130 INTRODUCTION WHO reported confirmed cases of Coronavirus disease 2019 (COVID-19) until July 22, 2020, amounting to 14,971,036 cases with 618,017 deaths worldwide (Case Fatality/CFR 4.1%). This disease affects all groups, including pregnant women. Pregnant women, as a population, can be more susceptible to infection, with high morbidity and mortality rates (Aziz, 2020). Based on data on positive confirmed cases of women There were 15,735 persons in the US in August 2020, which is 0.3% of the total population positive verified instances) (Rohmah & Nurdianto, 2020). 13.7% of pregnant women are more likely to contract Covid- 19 infection, according to data from the Indonesian Obstetrics and Gynecology Association (POGI) in Jakarta than non-pregnant individuals (Aziz, 2020; Rohmah & Nurdianto, 2020). This causes pregnant women to experience anxiety and even depression if not treated immediately. The COVID-19 pandemic can psychologically lead to increased levels of anxiety and stress brought on by fear of transmission and the effects thereof. During the COVID-19 pandemic, anxiety and depression were prevalent in pregnant women at 64.5% and 56.3%, respectively (Puertas-Gonzalez et al., 2021). The frequency of anxiety among expectant mothers is 36.77%: 25.34% with mild anxiety, 10.09% with moderate anxiety, and 1.35% with severe anxiety (E. et al., 2021). Women who are expecting are more susceptible to these psychological effects. (BPS Kota Kediri, 2020). During pregnancy, COVID-19 possesses an important impact on the results of prenatal and neonatal care. Since April 2020, the Indonesian Government has launched Mental Health Psychology Services (SEJIWA), that offers a hotline. Similarly, the Indonesian Psychological Association (HIMPSI) provides licensed psychologists and support with the increase number volunteers, as well as strengthening the ability to these employees of a both regional and national level. SEJIWA was the first to provide assistance with mental health for the people of Indonesia While COVID-19 was in the air. This service provided guidance for women impact of COVID-19, including female victims of domestic violence, women in emergency situations and special conditions (such as pregnant women), female migrant workers, and women with disabilities. One week after its inauguration, public complaints regarding SEJIWA's services were relatively low, with approximately 344 complaints from 2,978 calls received through 119 ext. 8, with a transfer call ratio of 11.55 percent. The COVID-19 outbreak of the coronavirus disease that originated a pandemic that started in China threatening worldwide health, therefore encouraging research aimed at early detection, prevention, and treatment of the disease (Tyastuti, 2016). According to a study on anxiety in pregnant women in the Majoroto district, 13 pregnant women (52%) experienced anxiety in the very severe category, 1 pregnant woman (4%) in the severe category, 3 pregnant women (12%) in the moderate category, 3 pregnant women (12%) in the mild category, and 5 pregnant women (20%) in the normal category. This prompted researchers to analyze the factors contributing to anxiety in pregnant women, as previous research failed to identify these factors. Therefore, this study aimed to Assessing anxiety in pregnant women and identify triggers for during the Covid-19 epidemic, anxiety. METHODS The design of the study was analytic with cross sectional design. This study was taken place in Mojoroto District, Kediri City. This study was conducted on February-August 2022. The group under examination was all expecting mothers in Mojoroto District, Kediri City with the sum of 80 expecting mothers. The sample in this studywere some pregnant women in Mojoroto District, Kediri City. The sample size obtained with the slovin formula was 67 respondents. The sampling technique used a cluster random sampling mechanism, a technique for determining samples from populations by grouping through region. Before conducting the study, an ethical test is carried out first, if ethically approval has been obtained then the research will be carried out. Prior to the research, the researcher arranged for a research permit to the relevant agency, if he had obtained permission, then approached the respondent to obtain informed consent. Data regarding factors that influence anxiety are collected online using the Questionnaire facility. After the data has been gathered, data verification is carried out first after collecting reliable data, the data tabulation procedure is carried out according to each research variable. The instrument used a questionnaire on the variables that affect anxiety. Identification of pregnant women's anxiety using DASS. The validity of the questionnaire was tested by Product Moment Correlation and the reliability test was carried out by Yanuarini, Kristianti, Kundarti Mansur, Antono, Factors Triggering Anxiety for Pregnant Women … 123 Cronbach's Alpha Coefficient Technique. The data collection process was carried out in collaboration with the cadres. The cadres help to coordinate and gather pregnant women who take part in the research. Processing and analysis of data The first stage was carried out descriptive analysis first, then bivariate analysis was carried out using the Spearman Rho test, then to find out the factors that influence anxiety were tested with The Ordinal Regression. SPSS 19 is the testing software. RESULTS Table 1: Age Group Age group Amount n % 16 – 20 6 8,9 21–25 12 17,9 26 – 30 20 29,9 31–35 13 19.5 36–40 14 20,9 > 40 2 2,9 Total 67 100 Based on Table 1 above, that the most age group is in the position of productive adults. Table 2: Pregnancy Trimesters Pregnancy Trimesters Amount n % I (One) 17 25,4 II (Two) 22 32,8 III (Three) 28 41.8 Total 67 100 Based on Table 2 above, that the most pregnancy trimesters are in the third trimester of pregnancy. Table 3: Pregnancy Complications Complications Amount n % Anemia 4 6 Preeclampsia 0 0 Concomitant Diseases 1 1.5 Other 1 1.5 There isn't any 61 91 Total 67 100 Based on Table 3 above, that most pregnant women do not experience pregnancy complications. 124 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 121-130 Table 4: Occupational groups Work Amount n % IRT 45 67,2 Private sector employee 10 14,9 Self-employed 7 10,4 Freelancer 1 1.5 Teacher 4 6 Total 67 100 Based on Table 4 above, that most pregnant women work as housewives. Table 5: Limited Food Materials Work Amount n % Yes 3 4,5 No 64 95.5 Total 67 100 Based on Table 5 above, that the most limited food ingredients are not experiencing food shortages. Table 6: Efforts to Prevent COVID-19 in Health Services Efforts to Prevent COVID-19 in Health Services Amount n % Yes 19 28,4 No 48 71.6 Total 67 100 Based on Table 6 above, the most anxious feelings of pregnant women about efforts to stop COVID-19 in health services are that they do not experience anxiety. Table 7: History of Depression of expectant mothers Amount n % Yes 3 4,5 No 64 95.5 Total 67 100 Based on Table 7 above, most pregnant women do not have a history of depression. Table 8: Environments with high Covid cases An environment with high Covid cases Amount n % Yes 33 49 No 34 51 Total 67 100 Based on Table 8 above, that the feeling of being in an environment where Covid cases are high is mostly not experiencing anxiety. Yanuarini, Kristianti, Kundarti Mansur, Antono, Factors Triggering Anxiety for Pregnant Women … 125 Table 9: Lost caregiver Lost nanny Amount n % Yes 14 21 No 53 79 Total 67 100 Based on Table 9 above, that the feelings of anxiety of pregnant women when they lose a caregiver are mostly not experiencing anxiety. Table 10: Statistical Test Results Factors affecting pregnant women's anxiety during a pandemic Variable Β p-values Information Pregnancy Complications 0.932 0.034 Significant Scarcity of food -6,470 0.047 Significant History of Depression 28,706 0.000 Significant An environment with high Covid cases 2,720 0.001 Significant lost caregiver 25,739 0.000 Significant Note: Ordinal Regression test to stop COVID-19 Table 10, the results of the Ordinal Regression statistical test, the variables of pregnancy complications, food scarcity, history of depression, anxiety about the environment and anxiety about losing caregivers have a p-value of less than α (0.000) which means they have an influence on the occurrence of anxiety for pregnant ladies in the year 19 of the COVID epidemic. DISCUSSION Pregnancy Complications Women who underwent surgical procedures While COVID-19 was in the air While COVID-19 was in the air are reported to have experienced symptoms of depression. These psychological effects are further exacerbated by a pre-existing medical condition.Abdul Latif et al., 2022). significant COVID-19 infection in significant COVID-19 infection or in sub-optimal health conditions is one of the growing concerns, besides fear of procedure-related complications and fear of post-hospital COVID-19 infection being the cause. (Abdul Latif et al ., 2022). Vomiting, in particular, has been shown can raise the risk of perinatal distress. women who have experienced extreme vomiting are more prone to psychiatric disorders such as depression and anxiety. Because vomiting can act in response physiologically to excessive pregnancy-related stress and vomiting symptoms may both be higher susceptible to COVID-19. Increased risk of more serious illness in people with ongoing medical issues. Pregnant people with ongoing medical issues. Pregnant conditions are more afraid of COVID-19 than healthy people (Giesbrecht et al., 2020). COVID-19 anxiety even after taking anxiety into account, remained a strong predictor, depression Includes more pertinent factors. This shows that COVID-19 anxiety is a factor in negative birth results (Giesbrecht et al., 2020). Age at conception is linked favorably with anxiety and depressive symptoms. Consequently, the most common complications pregnancy, including pre-eclampsia pregnant women's diabetes, are thought to occur late in pregnancy and contribute to a weakened immune system. In addition, a decrease in inherent immune system response in expectant mothers increases the mother's exposure to COVID-19 infection, causing higher pregnancy death, which can cause mother angst and depressive symptoms. (Luong et al., 2021).Pregnant women who experience vomiting and are considered vulnerable to SARS-CoV-2 infection experience increased birth anxiety. (Cui et al., 2021). Pregnant women with chronic health problems are more afraid of COVID-19 than healthy people (Giesbrecht et al., 2020). Limited food ingredients The results showed that food limitations are one of the factors that can cause anxiety. Individuals eating shortages had an increased likelihood of having levels of Depression and anxiety levels ranged from low to severe (mild: 32% vs. 23%, moderate: 15% vs. 7%, severe: 10% vs. 2%), respectively. Food insecurity While COVID 19 was in the air was reported to have a more than 5 times the chance of major depression. The significant link 126 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 121-130 between psychological discomfort and food hardship has significant implications for clinical guidelines and public health policies related not only to public health emergencies, but also to pregnancy in general.In addition to nutritional health, tackling food insecurity can also have a substantial effect on pregnant women's mental health. Not all people affected by food insecurity are entitled to government assistance types of government feeding programs like food banks and nutrition education programs. (Avalos et al., 2022). Limited food ingredients often cause pregnancy-related anxiety during COVID-19. Anxiety occurs because they are worried that the food ingredients will run out while the money to buy food is not enough due to social restrictions. In addition, the durability of food ingredients is also a problem in itself, most food ingredients are not able to last long, causing anxiety if they are damaged but replacements are not yet available. food safety, and nutrition issues the COVID-19 situation, which poses a major threat to has limited access too wholesome food. A healthy diet throughout COVID-19 outbreak is less inclined to develop anxiety and depression compared to a similar or less wholesome diet. (Luong et al., 2021). Restrictions during Covid-19 had a significant impact financial and social effect on affected families, namely experiencing economic difficulties and mental health problems. This impact worsens the family's condition in meeting food needs. Policies are needed in the form of support in terms of family income (Hannah Bryson et al, 2021) History of Depression Women who came forward having a mental health history conditions were more susceptible to exhibiting signs of anxiety and stress during pregnancy a pandemic pregnancy. This is consistent with other studies looking at predicting higher Pregnant women's anxiety and post-traumatic stress disorder levels. (Awad-Sirhan et al., 2022). Pregnant women with a history of psychiatric illness have been shown to be at increased risk of moderate or severe symptoms of general anxiety (Ilska et al., 2022). Having a current or previous mental illness is a risk factor for pregnancy anxiety. In addition, worldwide general population research have found that a history of current or earlier mental disorders is associated with adverse mental health effects with COVID-19 (Benke et al., 2020; Luo et al., 2020; Vindegaard & Benros, 2020 ). Woman under 40 years old gender, in touch with someone infected with COVID, history of psychiatry, performing a health a nurse or other professional who has been following the COVID-19 news for more than 3 hours per day increases the likelihood of experiencing depression, anxiety, and sleep issues. Many of these elements work via neuroinflammatory mechanisms in reaction to tension. In addition, Mental health patients frequently denied access to medical care, which continues to be a major issue (Kassaeva et al., 2022). Pregnant and postpartum women who report issues with mental health, present or past are more inclined to experience anxiety. As well as, women who reported more stressful life events outside of pandemics and worse social health problems during pregnancy were more likely to report increased depression (Lequertier et al., 2022). Reduced education level and a history of prior to the COVID- 19 pandemic, pre-existing anxiety has been identified as a predictor of mild to severe anxiety symptoms. (Morris et al., 2022). Environment Most pregnant women experience increased pregnancy anxiety during the pandemic. Respondents stated such pregnancy given the epidemiological scenario at the moment contributed to an increase in sensation of dread (Kicia et al., 2018). The COVID-19 pandemic's challenging epidemiological state, the associated constraints, as well as shifting socioeconomic changes, can also increase in the number of perinatal mothers developing psychological issues (Ahmad & Vismara, 2021; Brooks et al., 2020).Regions that encountered a sharp rise in cases, lockdowns and restrictions on maternity due to and maternity care the outbreak of the second wave of Covid reported an increase in depression three to four times (Lequertier et al., 2022). an anxiety or depression history is connected with an increase in symptoms of moderate to extreme phobia (Morris et al., 2022). Lockdownhas forced most the trend of staying at home by women less outings, enhancement workload at home, and caring as the sick, which contribute from psychological stress (Abdul Latif et al., 2022). Individuals with positive contact with COVID-19 (whether among friends, relatives, or family) report higher levels out of fear. Potentially higher risk of catching the illness from coming into contact with an a sick individual. Concern about the state of their social and economic contacts who have COVID-19 contract can contribute as well this Yanuarini, Kristianti, Kundarti Mansur, Antono, Factors Triggering Anxiety for Pregnant Women … 127 concern. An American study discovered that levels of fear of The Northeastern states, which are relatively near to the Maritime provinces, had the highest COVID-19 levels of Canada (Fitzpatrick K et al., 2020). The study's authors suggest that the region's higher fear of COVID-19 may be related to higher case numbers. Labor patients find being constant changes highly upsetting in limitations and regulations. Our research findings, pluswithour clinical knowledge, suggests that the worry of negative health effects associated with COVID-19 is simply a portion of the issue with pregnant women, adding to apprehensions about being pregnant during a pandemic (Giesbrecht et al., 2020). Restrictions on parent visits in newborn intensive care unit may make parents feel more stressed during this extraordinary health care emergency (Grumi et al., 2021). Social restrictions that apply wherever can be a significant issue that causes psychological anguish, because social assistance is very important in reducing the harmful consequences of anxiety and stress (Iwanowicz-Palus et al., 2022). Personal protective measures and the government's policies regarding the precautions are designated as danger elements; the quick authorities' response to a change in situations, on the other hand, is a preventative element (Kassaeva et al., 2022). Living in Victoria, Australia is connected with a four to five times increased likelihood of despair. Although the model regulated for the exposure to pandemics (regional number of cases/deaths, and duration) and many another COVID-19-related goal difficulties, Victoria observed a sharp rise in instances and additional lockdowns and restrictions on pregnancy care because the third wave of epidemic right before administrative a survey. The additional difficulties The difficulties Victorian women faced, as demonstrated here, may serve as these experiences (Lequertier et al., 2022). Pregnant Australian women report increased loneliness and diminished autonomy related to their maternity care experience as a result of restrictions on health services, which can aggravate the suffering women went through during this time of extreme vulnerability (Wilson et al., 2022). At the peak when asked about the COVID-19 pandemic-era stay-at- home lockdown in the United States, at least two in five (43.3%) responders in a sample of pregnant Americans who are women experienced depression and/or anxiety were at least 2.5 times as common than they were before the pandemic. in among expectant mothers (Liu et al., 2021). Anxious to Lose a Caregiver Prenatal sadness and/or anxiety symptoms that were more severe were linked self-reports with COVID-19, jobs that increase COVID-19 risk and distress due to Pregnancy care adjustments, job loss, childcare difficulties, and food insecurity (Avalos et al. , 2022). Changes in parenting were also significantly associated with an increased likelihood of anxiety and sadness. Similar results from other studies of expectant women during the COVID-19 pandemic have been published, underscoring the significance of public health policies in providing financial choices for assistance and child care, particularly during times of crisis (Avalos et al., 2022). During the perinatal period, Social assistance for moms reportedly declined during the COVID-19 the pandemic, and this was related to worse mental health. (Judy Zhou et al, 2021). Other research has also stated that parents experience increased anxiety around pregnancy, birth, worrying concerning their emotional health and mental well-being, and physical health. Increased anxiety also occurs due to reduced provision of health services, loss of social and familial support. Although only a small percentage of respondents mentioned some favorable effects from the lockdown, like increased family ties, numerous respondents claimed to feel alone, neglected and overpowering. This is of course related to the development and socialization of their babies.Alexandra Rhodes, et al, 2020). CONCLUSION Based on the study's findings, the main triggers for anxiety in pregnant women at the time of Covid- 19 pandemic were a history of depression and loss of caregivers. Meanwhile, pregnancy complications, limited food ingredients, and anxiety about the environment with high cases of COVID-19 are additional trigger factors. SUGGESTIONS Regional coverage needs to be expanded within the scope of the city or district so that the results can be used for decision making in the city or district. Variables that trigger anxiety are still lacking, so it needs to be examined by involving other variables. Modeling analysis will be better at describing interactions between variables in triggering anxiety in pregnant women. https://pubmed.ncbi.nlm.nih.gov/?size=100&term=Rhodes+A&cauthor_id=33264100 128 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 121-130 ACKNOWLEDGEMENT Financial support in this study was provided by the Poltekkes of the Ministry of Health Malang with a research contract no HK.03.01/1/0953/2022 dated February 7, 2022 concerning Research on Health Worker Development. FUNDING Financial support is provided by Poltekkes Kemenkes Malang starting from the preparation of proposals to reporting research results including research outputs. CONFLICTS OF INTEREST The authors declare no potential conflict of interest AUTHOR CONTRIBUTIONS The main researcher plays a role in preparing proposals and reporting results. 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