Ayşe T. Akduman1, Ayşe F. Türkçapar1, Tuğçe İçöz1, Özhan Özdemir1, Kazım E. Karaşahin1
1Department of Obstetrics and Gynecology, University of Health Science Turkey, Ankara Gulhane Training and Research Hospital, Ankara, Turkey (Correspondence: A.T. Akduman:
Abstract
Background: The COVID-19 pandemic caused social, economic, psychological, and physical effects in large segments of society; people’s lifestyles were affected, and their quality of life changed. Feelings of negativity may lead to the onset or exacerbation of adjustment disorders in sexual health, and this can change couple’s desire for parenthood.
Aims: To evaluate the change in the desire of married women to become mothers during the COVID-19 pandemic and the factors affecting it.
Methods: This was a cross-sectional study of 520 married Turkish women. Participants completed the self-administered survey of demographics and fertility preferences. The Fear of COVID-19 scale (FCV-19S), Patient Health Questionnaire (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) were used to measure fear, depression, and anxiety related to COVID-19.
Results: Fifty of 112 participants who were planning pregnancy before the pandemic abandoned this intention and reported that the pandemic had affected their plans. In contrast, 21 of 408 participants who had not planned pregnancy, reported that they planned a pregnancy during the pandemic. The main reasons were a desire to add positivity to their life, loneliness, increased leisure time, and intimacy with their spouse. Mean scores (standard deviation) for all participants for PHQ-9, GAD-7, and FCV-19S were 7.4 (6.02), 4.93 (4.84), and 17.28 (6.16), respectively.
Conclusion: This study highlighted the short-term effects of the COVID-19 pandemic on women’s fertility preferences, but more research is needed to examine the long-term effects.
Keywords: COVID-19, pandemic, fertility preferences, pregnancy plan, mental health
Citation: Akduman AT, Türkçapar AF, İçöz T, Özdemir O, Karaşahin KE. Fertility preferences and fears during the COVID-19 pandemic. East Mediterr Health J. 2023;29(x):xxx-xxx https://doi.org/10.26719/emhj/23.110
Received: 13/12/22, Accepted: 28/04/23
Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
The COVID-19 pandemic was declared by WHO in March 2020 (1, 2). According to WHO data, by 24 January 2023, 664 million people had been infected and > 6 million had died, and in Turkey, there were > 17 million confirmed cases and > 101 000 deaths (1).
The COVID-19 pandemic affected economic and social life as well as physical health. Major economic losses occurred in every country; salaries were often lowered and many people lost their jobs. The consequent decrease in income had social costs, such as psychological problems, loss of confidence, and alienation from the environment. During this period, women’s fertility preferences began to change and the national fertility rates declined (3, 4). Women’s childbearing intentions may change throughout their reproductive life as a result of learning the direct and indirect costs of parenting, according to their partner’s wishes, and whether their relationship is stable or not (5). A serious health condition can also significantly influence the desire for childbearing (6). Uncertainty about the COVID-19 pandemic further complicated women’s attitudes towards future pregnancy. A study from Italy reported that > 30% of people planning to become parents before the pandemic avoided pregnancy, but 11.5% of participants had an increased desire for pregnancy during quarantine (7). It is unclear whether the COVID-19 pandemic will lead to a decline in births globally (8). In the early stages of the pandemic, short-term changes were observed in several developed countries but returned to normal levels within a short time. The situation in low- and middle-income countries was similar to that in developed countries (9). Temporary fluctuations in fertility rates have been observed previously in other crises in many countries, such as the global economic recession in 2008, when economic hardship and unpredictability about the future caused short-term declines in fertility (10).
In this study, we aimed to determine the change (or stability) in individual fertility preferences of women of reproductive age in Turkey during the COVID-19 pandemic. We also aimed to highlight the effects of the pandemic on the mental health of the general public and healthcare workers and to explore how pandemic fear may affect women’s future childbearing desire.
Methods
Study design and population
This was a questionnaire-based cross-sectional study conducted among 520 women in Ankara Gülhane Training and Research Hospital as patients, companions, or employees between 11 March and 11 May 2021, which coincided with the increase and peak of COVID-19 infection, and social restrictions were in effect. At that time, COVID-19 vaccines were not available and none of the participants were vaccinated. The inclusion criteria were: (1) age 18–45 years; (2) married for at least 1 year; (3) a minimum primary school education; and (4) sufficient language proficiency to understand the survey questions. Exclusion criteria were: (1) women who were already pregnant; (2) a history of infertility; and (3) refusal to take the survey. Demographic variables included age, number of children, household income, employment status, current education level, and chronic somatic and mental illnesses (Table 1).
Power analysis was performed using the GPower program (v3.1.9.7) to determine the sample size. The power of the tests used in this study, 1 β (β = type II error probability) was determined as 10%, and the effect size was 0.51 to obtain 90% of the power at the level of α=0.05. The GPower test revealed that there should be at least 475 people in the study. Considering the possibility of data loss, 10% more participants were included, which gave a total of 520 participants.
The self-administered questionnaire was designed to evaluate the effects of the COVID-19 pandemic on couples’ quality of life and mental health, and women’s fertility preferences. The questionnaire consisted of closed and open-ended questions including demographic, factual, and attitude questions by examining the variables in previous studies on the subject (6, 11, 12). The Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Assessment (GAD-7), and Fear of COVID-19 Scale (FCV-19S) were used to assess the participants’ mood during the pandemic. In terms of intelligibility of the form, it was tested in a small number of groups with similar inclusion criteria before the implementation.
Fertility preferences
Fertility preferences before and during the COVID-19 pandemic were evaluated. Participants reported whether the pandemic had changed their fertility preferences. Participants were asked about what influenced their decisions and various response options were presented. The questions included a range of variables measuring the living conditions of the participants that may have influenced their fertility desires, such as the average time spent at home with a partner during the day. Socioeconomic factors, such as being away from home for work and difference in monthly household income compared with the prepandemic period, were investigated. The participants stated whether they had chronic diseases that could affect a future pregnancy, such as hypertension or diabetes. The participants were asked whether they or their spouses had COVID-19 and any consequent losses. The desire for childbearing domains was also analysed in 2 separate groups, one contained healthcare workers, and one did not.
Mental health
The participants were screened for symptoms of depression and anxiety using FCV-19S, PHQ-9, and GAD-7, which were validated in Turkish and proven to be valid and reliable (14, 16, 18).
FCV-19S
We used FCV-19S to determine participants’ fear of COVID-19. FCV-19S is a survey that assesses the fear associated with the global pandemic (13), and comprises 7 statements, including “It makes me uncomfortable to think about COVID-19” and “I am afraid of losing my life because of COVID-19”; each with a 5-point Likert scale of options. Participants were asked to choose the option that best represented them for each statement. The total score ranged from 7 to 35, with higher scores indicating increasing fear of COVID-19.
GAD-7
GAD-7 is a 7-item scale measuring the severity of anxiety experienced in the past 2 weeks. There are 4 options representing the severity of symptoms: never, few days, more than half a day, and almost every day, corresponding to 0, 1, 2, and 3 points, respectively. The total score is 0–21 (15). The cutoff value was determined as 10 in this study.
PHQ-9
PHQ-9 is widely used to diagnose depression symptoms in the general population, and is a valid and reliable 9-item scale with 4 Likert-type responses covering Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria (17). Items examining depression symptoms in the past 2 weeks can be answered as: not at all, several days, more than half the days, and nearly every day; which have a value of 0, 1, 2, and 3 points, respectively (total score 0–27). The cutoff value was determined as 10 in this study.
Ethical approval
Ethical approval for the study was obtained from the Turkish Ministry of Health and by the Non-Interventional Ethics Committee, University of Sağlık Bilimleri Health Science, Ankara Gülhane Training and Research Hospital (IRB No: 2021/121). The study protocol complied with the Declaration of Helsinki. The study participants were informed that the data obtained from the survey would be used in a scientific study and their consent was obtained. The names and personal data of the respondents were not recorded. Every stage of the study was carried out in accordance with the relevant guidelines and regulations.
Statistical analysis
Statistical analysis of the data was done with SPSS for Windows version 11.5 (Chicago, IL, USA). The 2 test was used to compare groups for categorical data and 2-group comparison of quantitative variables. The independent samples t test was used to compare 2 sample means from unrelated groups. The Bonferroni test was used post hoc to detect different groups when significant differences were found after one-way analysis of variance. P < 0.05 was considered to be statistically significant .
Results
Participant characteristics
There were 520 women in the study and 245 (61.1%) were working in the healthcare sector. Basic demographic and socioeconomic characteristics of the study population are summarized in Table 1. Approximately 25% (n = 127) of the participants tested positive for COVID-19, and 36 (6.9%) were asymptomatic, 88 (16.9%) had mild symptoms, and 3 (0.6%) had moderate/severe symptoms. The spouses of 114 (22.0%) participants tested positive for COVID-19 and 220 (42.3%) participants experienced the death of an acquaintance from the disease.
Pregnancy during the pandemic
We found substantial evidence of a reduction in the mean fertility trend during compared with before the pandemic (P < 0.05) (Table 2). Of the 112 (21.5%) participants who planned pregnancy before the pandemic, 50 (44.6%) abandoned this intention. The main reasons for this decision included concerns about: the possible adverse effects of SARS-CoV-2 on pregnancy or the baby (n = 28; 56.0%); the economic well-being of the household (n = 14; 28.0%); and their own health (n = 8; 16.0%). Of the 408 (78.5%) participants who did not plan to become pregnant, 21 (5.14%) stated that they had a desire for pregnancy during quarantine. In 12 (57.14%) participants, the main reason was to add positivity to life. Other common reasons were loneliness, leisure time, and intimacy with their partner.
COVID-19 positivity in participants or their spouses did not affect their fertility preferences (Table 3). However, a significant number of participants who planned pregnancy before the pandemic and whose relatives died from COVID-19 decided not to become pregnant during the pandemic (P = 0.013).
Mental health
We used PHQ-9, FCV-19S, and GAD-7 to evaluate various indicators of mental health and well-being during the COVID-19 pandemic and their effect on women’s desire to plan a pregnancy. Mean scores and standard deviations of all participants were: PHQ-9, 7.4 (6.02); GAD-7, 4.93 (4.84); and FCV-19S, 17.28 (6.16). Mean scores in healthcare workers were: PHQ-9, 7.72 (6.06); GAD-7, 5.19 (4.93); and FCV-19S, 17.05 (6.20). The mean scores of the PHQ-9, GAD-7 and FCV-19S did not differ between healthcare professionals and the other participants.
There was no significant association between fertility preferences and PHQ-9, FCV-19S, and GAD-7 scores (Table 4).
The conditions examined by PHQ-9, FCV-19S, and GAD-7 were more severe in participants with low income, chronic illness, and a history of psychiatric illness (all P < 0.05) (Table 5). Participants who spent more time at home with their spouse (≥ 18 hours) had significantly lower scores (P = 0.001). FCV-19S was significantly higher in participants who had a friend or relative who died from COVID-19 (P = 0.005).
Discussion
Pregnancy and becoming a mother are important life events that affect women on psychological, social, physical, and existential levels. From the perspective of existential psychology, making sense of life and living conditions is essential and creates a strong motivation to live (19). Over the past 50 years, there has been a steep decline in fertility rates in almost every country. This universal decline in fertility has been driven largely by increased welfare brought about by social factors, including women’s education and the accompanying detachment from reproduction as the purpose of life (20). The trend to give up childbearing is affected by many other factors, such as age and parity, divorce or child death, health conditions, economic situation, and personal health perceptions (6).
The COVID-19 pandemic has led to contradictory changes in couples’ fertility preferences (4, 21). In the present study, approximately half (45.5%) of the participants reported behavioural changes and a decision to postpone pregnancy because of the pandemic. A study conducted in the United States of America (USA) reported that > 30% of participants delayed pregnancy or had a decreased desire to have children because of the pandemic (22). In contrast, they also reported that 10–20% of participants who had not thought of having children before, now wanted to have children, or to have them earlier. A study conducted in the United Kingdom of Great Britain and Northern Ireland reported that the COVID-19 pandemic affected pregnancy plans and 72% of the participants delayed pregnancy for pandemic-related reasons (23). Concerns were mostly about changes in prenatal care, but also fears about the negative effects of the virus on pregnancy and infants. In contrast, 27% of respondents reported prioritizing their pregnancy plans by readjusting their priorities during this period. A study conducted in Australia found that there was a significantly greater decrease in reported intentions to have another child among women who experienced prolonged curfew (21). However, it should be noted that most of these studies were cross-sectional with small convenience samples.
Giving birth is one of the most important events in a woman’s life, but it naturally brings some level of anxiety. In our study, the most frequent reasons for women giving up or delaying childbearing were the possible adverse effects of SARS-CoV-2 on pregnancy or their infant, and concerns about their own health. Factors such as the possibility of vertical transmission of SARS-CoV-2 or barriers to accessing the needed professional medical help may affect the desire to become a parent. Also, women may have felt anxious about the risk of exposure to COVID-19 during hospital visits while pregnant (24, 25). A large-scale study conducted in Sweden reported that pregnant women’s concerns about their own and their infant’s health were at higher-than-normal levels during the pandemic (26). A cross-sectional study conducted in the Islamic Republic of Iran showed that fear of infection in pregnant women worsened mental health (27). We found that although participants cited financial and health concerns caused by the pandemic as reasons for abandoning or delaying pregnancy; surprisingly, there was no significant association between fertility preferences and FCV-19S, PHQ-9, and GAD-7 measurements.
Past economic hardship can strongly influence the dynamics of marriage, divorce, fertility, death, and migration. During times of economic hardship, couples’ fertility decisions often differ by gender, age, number of children, and ethnicity (28). Unemployment during economic crises affects women and men of reproductive age in many ways. In 22 countries in the Organisation for Economic Co-operation and Development, the increase in both male and female unemployment during 1976–2008 had a negative impact on total fertility rates, which was greater over time, especially for women (29). We also found that financial concern was among the main reasons for fertility preferences. The household income of 23.4% of the participants decreased during the COVID-19 pandemic, 4.6% quit their job, and 4.8% of their spouses quit their job. However, these factors did not significantly delay pregnancy. In a cross-sectional study of 1179 women in New York, USA, between 30% and 80% of respondents who had intended to become pregnant within the year before the COVID-19 pandemic had delayed or cancelled their plans because of increased stress and financial insecurity (30).
The COVID-19 pandemic and measures to contain it caused additional health problems, including anxiety, depression, and fear worldwide (31). However, it is still unclear to what extent the pandemic affected mental health in the general population. In our study, mean scores for FCV-19S, PHQ-9, and GAD-7 were high in patients with previous psychiatric illness or concomitant chronic diseases. A study in Turkey suggested that the groups most affected by the pandemic were women, people living in urban areas, and those with previous psychiatric illness or concomitant chronic diseases (32). In a systematic review, increases in depression and mood disorder symptoms were more pronounced compared with measures of anxiety and general mental health, and these increases were greatest in people with physical health problems (33). No evidence of any change in symptoms was detected among people with a pre-existing mental health condition. COVID-19 has undoubtedly had some impact on the mental health of healthcare providers. In Singapore, 27% of healthcare workers experienced psychiatric symptoms during the pandemic (34). Similarly, during the Ebola outbreaks that emerged in Africa in 2014 and 2018, high levels of anxiety were reported among people who had direct contact with infected patients, partly due to stigma (35). In the present study, however, no significant difference was found in FCV-19S, GAD-7, and PHQ-9 scores between health and other workers. Also, no significant difference was found in fertility preferences between these groups.
Our study had some limitations. First, the study was limited to a small part of the Turkish population, so generalization of the findings to other pandemic settings should be done with caution. Second, our research on pregnancy intention relied on retrospective assessment, so it may have been affected by recall bias. However, predictions that pandemics will become more frequent in the future make this study an important contribution to the literature by analysing the links between pandemic-related restrictions and fears and fertility behaviour.
Conclusion
This study supports the previously reported preference of women for delaying or preventing pregnancy during the COVID-19 pandemic. We showed that uncertainty and anxiety brought about by the pandemic had a negative impact on the fertility intentions of the participants. Research on economic recession and fertility has shown that situations that affect living conditions often lead to delays in pregnancy, especially for first births, but there is an increase in fertility once the uncertainty created by the pandemic ends or economic concerns subside (36). Our study belongs to the pre-COVID-19 vaccine period, and the findings may be different in the post-vaccine period. Further, prospective investigations in larger populations are needed to confirm our results, so that estimates of fertility preferences can be interpreted accordingly. The possible impact of the COVID-19 pandemic on stress, sexual activity, and concerns about health during pregnancy and infant health should be investigated.
Conflict of interest: None.
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