The outbreak of coronavirus disease 2019 (COVID-19) leads to a declaration of a serious level of response on 4 January 2020, which was escalated to the emergency level on 25 January 2020.1 2 Corresponding policies were imposed by the Hospital Authority at that time. Visiting periods were suspended, and mask wearing became mandatory in hospitals. In obstetrics, companionship during childbirth was stopped, as were visits to newborns staying with mothers in the postnatal ward. All prenatal exercise, antenatal talks, hospital tours, and postnatal classes were cancelled. The infection continued to spread worldwide, and a pandemic was declared by the World Health Organization on 11 March 2020. The first case of a COVID-19-infected pregnant mother was confirmed on 20 March 2020. The Hong Kong Government has further restricted travel and tightened social distancing and other measures to limit the spread of COVID-19.

Increased psychological stress and anxiety levels have been reported in countries with major outbreaks.3 4 As reflected by the Edinburgh Postnatal Depression Scale (EPDS), pregnant women assessed after the declaration of the COVID-19 epidemic had significantly higher rates of depressive symptoms than women assessed before the announcement in China.5 6 Behavioural changes have also been recognised among pregnant women.7 This evolving situation and its concomitant alterations in obstetric care can potentially pose extra psychological stress during the peripartum period.

In our university-affiliated tertiary hospital in Hong Kong, screening for women at risk of or having emotional problems is performed for all pregnancies antenatally during a booking visit. Counselling and support are provided by trained midwives and nurses from Comprehensive Child Development Service to those in need. Postpartum depression is routinely assessed after delivery using the validated EPDS.8 9 The aim of the present study was to examine the effect of COVID-19 and its concurrent service adjustments on couples’ obstetric planning and postpartum depression.

This was a retrospective study of the delivery data and EPDS scores of women who delivered at Queen Mary Hospital in Hong Kong from 1 January 2019 to 30 April 2020. Information related to the original number of bookings, actual deliveries, childbirth companionship, basic demographics, mode of delivery, epidural rate, and other methods of pain relief were retrieved from the Clinical Information System and Clinical Data Analysis and Reporting System of the Hospital Authority.

Screening for postpartum depression was performed routinely by asking all women to complete the EPDS questionnaire 1 day after delivery. This assessment was conducted again by phone within 1 week after delivery. The EPDS consists of 10 questions with a maximum score of 30 and has a validated Chinese version.9 10 A cut-off of ≥10 was adopted locally. Women with high scores were counselled by a dedicated team of midwives and psychiatric nurses.

Comparisons of delivery data and EPDS scores were performed between women who delivered during the pre-alert period (1 Jan 2019 to 4 Jan 2020) and the post-alert period (5 Jan 2020 to 30 Apr 2020). Analysis was performed using SPSS (Windows version 25; IBM Corp, Armonk [NY], United States). Student’s t tests and Chi squared tests were used as appropriate with P<0.05 considered as statistically significant.

There were 1997 pregnant women with expected delivery dates between January 2020 and April 2020 booked for delivery at Queen Mary Hospital, as compared with 1869 bookings for the corresponding 4-month period in 2019. However, there was a 13.1% reduction in the number of actual deliveries between 1 January and 30 April, from 1144 in 2019 to 994 in 2020. Fewer than half of the total number of women who originally booked for delivery in our hospital eventually delivered there, and the drop was more profound from February to April 2020. As a result, there were 3577 deliveries from 1 January 2019 to 4 January 2020 (ie, the pre-alert group) and 954 deliveries from 5 January 2020 to 30 April 2020 (ie, the post-alert group).

A significantly higher proportion of Chinese women (85.1% vs 81.5%; P<0.05) delivered during the post-alert period, while proportion of women with labour companionship was significantly reduced (21.8% vs 88.8%; P<0.05) compared with the pre-alert period. For pain relief during labour, more women received pethidine injections and fewer women used a birthing ball during the post-alert period. The other parameters were comparable between the two groups (Table 1).

Out of 4531 total deliveries, EPDS scores were available for 4357 (96.2%) 1 day after delivery and 3772 (83.2%) within 1 week after delivery. A significantly higher proportion of women had EPDS scores of ≥10 1 day after delivery in the post-alert group compared with the pre-alert group (14.4% vs 11.9%; P<0.05). This proportion was reduced to 2.9% on the second assessment within 1 week of delivery, at which point the scores became comparable with those of the pre-alert group (2.3%).

Compared with the first assessment 1 day after delivery, women in both groups demonstrated significantly lower mean EPDS scores on the second assessment within 1 week (pre-alert group: 4.71 vs 1.36; post-alert group: 4.93 vs 1.42; P<0.01). The mean EPDS scores obtained on both 1 day (4.93 vs 4.71) and within 1 week (1.42 vs 1.36) after delivery were higher following the declaration of alert response, although the difference was statistically insignificant. The monthly mean EPDS score 1 day after delivery was higher during the post-alert period (range, 4.87-4.99) than during the pre-alert period (4.71; 95% confidence interval=4.57-4.85; Table 2).

The present study is the first to report the impact of COVID-19 on obstetric care and postpartum depression in Hong Kong. The delivery rate in public hospitals has dropped dramatically in the post-alert period. This drop has been more profound since February 2020, especially among non-Chinese women. As of 30 April 2020, there had been three confirmed COVID-19 cases in pregnant women in Hong Kong. Although local changes in public health behaviour, social distancing, and isolation have largely contained the local outbreak of COVID-19,2 these policies could disrupt couples’ delivery plans. The reduced delivery rate could represent a shift of childbirth from public hospitals to private ones that did not manage suspected or confirmed COVID-19 patients. Non-Chinese women might have returned to their home countries out of fear of COVID-19. Women who deliver in public hospitals now increasingly have to face the challenge of childbirth without the companionship of family members and complete their hospital stay without visitors. All of these could account for the reduced delivery rate in the public sector.

Another important finding was the increased proportion of women with high EPDS scores in the post-alert period. We observed an increase in EPDS scores shortly after delivery during the post-alert period. This aligns with the findings of a multicentre study conducted in China following the announcement of human-to-human transmission.6 The COVID-19 pandemic could cause health anxiety and postpartum depression.7 11 Women of reproductive age in Hong Kong experienced the severe adult respiratory syndrome epidemic in 2002 to 2003. Thus, these women are potentially more stressed than those in other countries. An emergency response was raised in Hong Kong even before the declaration of a pandemic by the World Health Organization. The practice of mask wearing has been widely adopted previously, and supplies have been in huge demand in the past.1 The memories of severe acute respiratory syndrome coupled with the abrupt changes in social behaviour during the post-alert period might have triggered more stress in pregnant women and been reflected in their EPDS scores. Moreover, those who remained in the public system might not have had alternative delivery options elsewhere. Pregnant women are vulnerable to postpartum depression, and early identification and effective intervention from Comprehensive Child Development Service might help to relieve these women’s stress. These adverse effects could also potentially be ameliorated by the provision of online education materials, a lactation support hotline, early postnatal discharge, and family support.

Childbirth is a major life event for a family. Companions can provide information about childbirth, bridge communication gaps between healthcare workers and women, and facilitate non-pharmacological pain relief. They can also provide practical support, including encouraging women in labour to move around, providing massages, and holding their hands.12 The overall usage of non-pharmacological pain relief was similar between the pre- and post-alert periods. However, a significantly lower proportion of women used a birthing ball for pain relief during labour in the post-alert period, probably secondary to the suspension of childbirth companionship. Fewer women received childbirth massages, as they are usually provided by companions. Contrary to this, more women needed pethidine injections during labour. This indicates the contributory role of childbirth companionship to women’s overall birthing experience.

The present study illustrates the impact of COVID-19 on pregnant women’s delivery plans and the need for attention to their emotional disturbance. This is important information for obstetricians to consider during the revision and adjustment of service provision. Remedial measures like teleconferencing and early postnatal discharge can facilitate speedy recovery from distress. Although we noted increased levels of postnatal depression in the post-alert period, this study was not designed to study the contributory effects of COVID-19, cessation of childbirth companionship, or elimination of visiting hours to postnatal depression. Another limitation is the lack of data on anxiety levels, which could provide a more comprehensive picture of the pregnant women’s emotional health. Moreover, this review is limited to the assessment of women who ultimately delivered in our hospital. Such women might be more adaptive and prepared for the altered environment than those who chose to give birth in the private sector or abroad. As the study was restricted to one public hospital, the findings might not be generalisable to hospitals in other catchment areas, which may have different population characteristics. The policies of restricted gathering and social distancing might affect the arrangements of family celebrations, baby showers, and the cultural practice of ‘doing the month’. It will be of interest to examine whether women’s stress and anxiety levels change during the later postnatal period. Further study is warranted to examine the social and psychological responses of pregnant women during the COVID-19 pandemic.

Measures to limit the spread of COVID-19 have resulted in fewer deliveries in our public hospital and more symptoms of postpartum depression. Obstetricians should be aware of these effects on the psychosocial well-being of pregnant women and offer timely intervention to provide stress relief.

Concept or design: All authors.
Acquisition of data: PW Hui, G Ma, MTY Seto.
Analysis or interpretation of data: PW Hui.
Drafting of the manuscript: PW Hui.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank all midwives and nurses for their contributions to the assessment of postnatal depression in women who delivered at Queen Mary Hospital.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research has been approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority West Cluster (HKU/HA HKW IRB; Ref UW 20-419).

1. Leung GM, Cowling BJ, Wu JT. From a sprint to a marathon in Hong Kong. N Engl J Med 2020;382:e45. Crossref

2. To KK, Yuen KY. Responding to COVID-19 in Hong Kong. Hong Kong Med J 2020;26:164-6. Crossref

3. Moghanibashi-Mansourieh A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J Psychiatr 2020;51:102076. Crossref

4. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza- Gorrochategui M, Idoiaga-Mondragon N. Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the Northern Spain [in English, Spanish]. Cad Saude Publica 2020;36:e00054020. Crossref

5. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729. Crossref

6. Wu Y, Zhang C, Liu H, et al. Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China. Am J Obstet Gynecol 2020;223:240. e1-9. Crossref

7. Corbett GA, Milne SJ, Hehir MP, Lindow SW, O’Connell MP. Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic. Eur J Obstet Gynecol Reprod Biol 2020;249:96-7. Crossref

8. Leung WC, Kung F, Lam J, Leung TW, Ho PC. Domestic violence and postnatal depression in a Chinese community. Int J Gynaecol Obstet 2002;79:159-66. Crossref

9. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6. Crossref

10. Lee DT, Yip SK, Chiu HF, et al. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 1998;172:433-7. Crossref

11. Rashidi Fakari F, Simbar M. Coronavirus pandemic and worries during pregnancy; a letter to editor. Arch Acad Emerg Med 2020;8:e21.

12. Bohren MA, Berger BO, Munthe-Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019;(3):CD012449. Crossref