Reported experienced stress during the COVID-19 pandemic and patient preferences for the consultation of periconception blended lifestyle care: a survey among (pre)pregnant women

Abstract Purpose To assess experienced stress on different aspects of life and evaluate patient preferences for the consultation of periconception blended lifestyle care, combining face-to-face counseling with eHealth, during the COVID-19 pandemic among (pre)pregnant women. Using this two-fold aim, we were able to analyze the levels of stress among (pre)pregnant women during the COVID-19 pandemic, and to study whether their preferences for the consultation modality of periconception blended lifestyle care was influenced by the levels of stress. Methods A quantitative survey among (pre)pregnant women who received blended periconception lifestyle care between March 2020 and December 2021, from the first until the fourth COVID-19 wave in the Netherlands. The questionnaire used a 5-point Likert scale and measured experienced stress and preferred periconception blended lifestyle care modality. Results 984 women (response rate: 55.2%) filled out the questionnaire. Experienced stress during the COVID-19 pandemic was relatively low and stable over time. The highest percentage of respondents (31.2%) reported to have experienced stress on fertility and pregnancy. 40.4% (309/764) of the respondents indicated that face-to-face consultations could be replaced by digital consultation. Additionally, the mean experienced stress did not differ between the patients who preferred a video consultation (2.60 ± 1.1), or a telephone consultation (2.57 ± 1.2), either a video or telephone consultation (2.54 ± 1.3), still preferred a face-to-face consultation (2.41 ± 1.4) (p = .83). Conclusions Our findings indicate willingness for wide implementation of telemedicine within health care delivery, and reorganizing of periconception blended lifestyle care toward personalized and value-based health care.


Introduction
The COVID-19 pandemic had a major impact on health care systems and caused a public mental health crisis as well.Nearly a third of the general population experienced stress during the first year of the COVID-19 pandemic [1], related to the uncertainty about virus characteristics, unprecedented large-scale quarantine measures, shortages of medical protective supplies, medical professionals, and hospital beds, and misinformation on social media [2].Especially for women contemplating pregnancy or already pregnant, additional stress could be attributed to concerns and conflicting reports about the consequences of corona infections and the safety of corona vaccines [3].More importantly, excessive maternal stress is associated with increased risks of adverse pregnancy outcomes, such as preterm birth and low birth weight [4], having long term health consequences for their offspring during the life course [5].Previous studies already reported increased levels of stress among pregnant women during the COVID-19 pandemic [6,7].However, women contemplating pregnancy were not included, and stress was not further categorized.
Due to the COVID-19 pandemic, face-to-face hospital visits are increasingly replaced by telephone or video consultations, to decrease the risk of transmitting the virus to either patients or health care professionals.A rapid adoption of telemedicine, as health care services being delivered by health care providers in a patient-centered manner, from a geographical distance, using ICT (Information and Communication Technology), was forced in all fields of health care [8][9][10].Previous studies showed that patients were reluctant to visit the hospital, and experienced stress and anxiety to get infected [11][12][13].However, it is unknown whether (pre)pregnant women are experiencing excessive stress from visiting the hospital during COVID-19 and whether offering consultations remotely could benefit their healthcare experience.
In 2018, we implemented and evaluated periconception blended lifestyle care, combining a face-toface counseling with the 26-weeks eHealth coaching program Smarter Pregnancy (www.smarterpregnancy.co.uk, www.slimmerzwanger.nl).This health care service is a proven effective method to increase healthy lifestyle behaviors among (pre)pregnant women and their partner [14].Due to the COVID-19 pandemic and its mitigation measures, a part of the face-to-face lifestyle counseling consultations were quickly replaced by a telephone or video consultation.
The aim of this study was first to assess experienced stress on several aspects of life during the COVID-19 pandemic and, second, to evaluate patient experiences with and preferences for the consultation modality of periconception blended lifestyle care among (pre)pregnant women.Using this two-fold aim, we were able to analyze the levels of stress among (pre)pregnant women during the COVID-19 pandemic, and to study whether their preferences for the consultation modality of periconception blended lifestyle care was influenced by the levels of stress.This approach yielded information how to offer periconception blended lifestyle care now, and during possible future pandemics.

Study design and participants
A survey was designed using a health care evaluation questionnaire.This questionnaire was send out to women who received periconception blended lifestyle care between March 17 2020 and December 17 2021 at the department of Obstetrics and Gynecology.All couples contemplating pregnancy or in the first trimester of pregnancy visiting the outpatient clinics of reproductive medicine or obstetrics received periconception blended lifestyle care and were, subsequently, invited to fill out the questionnaire four weeks after they had the lifestyle counseling session.The workflow is visualized in Figure 1.

Measurement instruments
A questionnaire (Supplemental Table S1) to evaluate patient satisfaction with periconception blended lifestyle care was composed by three clinically and scientifically experienced professionals involved in the development and provision of blended periconception lifestyle care.An implementation expert was consulted for advice on the content and formulation of the questions.Ten additional involved medical doctors, as well as relevant patients scored the relevance of each question.Questions with a mean relevance score of eight or higher (range 0-10) were included in the questionnaire.Eventually, the questionnaire consisted of 28 questions, 19 questions concerning the content and satisfaction with the provided blended care, 4 questions regarding preferences on consultation modality, and 5 questions related to stress during the COVID-19 pandemic on different aspects of life, such as stress in general, about own health and well-being, about family, fertility or pregnancy, financial situation, work situation, visiting the hospital, and getting infected with SARS-CoV-2 during hospital visit.A respondent could specify her level of agreement to a specific statement in five points: (1) strongly disagree; (2) disagree; (3) neutral; (4) agree; (5) strongly agree.

Study participants and data collection
Patients who had received blended periconception lifestyle care were invited to fill out the questionnaire four weeks after they had the lifestyle counseling session.They received the invitation digitally or by mail, depending on their preferences.Two weeks after the initial invitation, a reminder was send when the questionnaire was not completed.

Data analyses
Geographic origin was categorized as Western (woman was born in a country in North America, Oceania or Europe, Turkey excluded) or Non-Western (woman was born in Turkey or a country in Africa, Asia or South America).
The results from the evaluation questionnaire were presented as percentages of answers given on each category of the 5-point Likert scale (1 (low) À 5 (high)).Mean overall experienced stress between the coronavirus waves were compared using a t-test and trends over time were visualized in a figure.
For the comparison of the mean experienced stress between the groups that preferred, respectively, a faceto-face, video, or telephone consultation, the one-way analysis of variance (ANOVA) was used.ANOVA was used as well to determine whether there are any statistically significant differences in mean experienced stress on different aspects of life between groups based on parity, geographical origin, and pregnancy status.Correlation coefficients were calculated between different aspects of stress using Spearman's correlation.

Informed consent
Informed consent was obtained from all individual participants included in the study.Ethical approval to publish the results of this health care evaluation was granted by the medical ethics and institutional review board of the Erasmus MC, University Medical Center, Rotterdam, Netherlands.

Results
The questionnaire was sent out to 1781 patients who received the blended periconception lifestyle care between March 17 2020 and December 17 2021.In total 984 patients filled out the questionnaire (response rate 55.2%).The survey completely coincides with the several COVID-19 mitigation lockdowns in the Netherlands.

Characteristics of respondents
The median age of the respondents was 33.0 years and 513 respondents (52.1%) were pregnant.640 women (65.0%) were Western, and 344 (35.0%) had a non-Western origin.The majority (58.9%) received the lifestyle counseling through a face-to-face appointment, 32.0% had a video consultation and 9.0% had a telephone consultation.

Experienced stress
Respondents were asked if they had experienced stress during the COVID-19 pandemic on different aspects of life, such as stress in general, about family, fertility or pregnancy, financial situation, work situation, visiting the hospital, and getting infected with SARS-CoV-2 during hospital visits.The highest percentage of respondents (259/831, 31.2%) reported to have experienced stress on fertility and pregnancy, and 27.7% (229/828) on health of family and 22.2% (185/832) declared to have experienced stress in general.Stress caused by visiting the hospital and stress to get infected in the hospital was reported by 10.6% (88/833) and 7.8% (65/831), respectively.
Between the first and third corona wave in the Netherlands (mid-March 2020-March 2021), stress on all the evaluated aspects of life decreased (Figure 2).However, during the fourth corona wave (November 2021), we observed an increase in experienced stress on fertility and pregnancy (2.70-3.12;p ¼ 0.06).
Figure 3 shows a correlation matrix of experienced stress on different aspects of life.All aspects were positively correlated.Strong correlations were between stress in general and stress concerning own health (rs(829) ¼ .70,p ¼ <.001) and between stress concerning health of their own family and stress concerning their own health (rs(827) ¼ .75,p ¼ <.001).Additionally, stress due to hospital visits correlated strongly correlated with stress to get infected in the hospital (rs(829) ¼ .78,p ¼ <.001).Experiencing stress regarding financial situation showed strong correlation with work-related stress (rs(823) ¼ .65,p ¼ <.001) and not with stress on other aspects of life.
Non-Western women were more likely to experience stress on all aspects of life compared with Western women, mainly stress about finance and stress about getting infecting in the hospital (b ¼ 0.504, SE ¼ 0.08; p ¼ <0.001; b ¼ 0.537, SE ¼ 0.07, P ¼ <0.001).Moreover, pregnant women reported higher stress levels on several aspects of life, mainly about their own health (b ¼ 0.237, SE ¼ 0.08, p ¼ 0.01), and lower stress levels about pregnancy and work (b ¼ À 0.242, SE ¼ 0.

Replacement by digital care modalities
Nearly half of the respondents (312/764, 40.8%) felt content with the replacement of a face-to-face consultation by a video or telephone consultation.Correspondingly, 40.4% (309/764) reported that future

Main findings
Experienced stress during the COVID-19 pandemic among (pre)pregnant women was relatively low, remained stable and even decreased temporarily over time.The highest percentage of respondents (31.2%) reported to have experienced stress on fertility and pregnancy.Non-Western women were more likely to experience stress on all aspects of life compared with Western women.The association with geographical origin was the strongest with stress about the personal financial situation and stress about getting infecting in the hospital (b ¼ 0.504, SE ¼ 0.08; p ¼ <0.001; b ¼ 0.537, SE ¼ 0.07, p ¼ <0.001).The association between experienced stress on all aspects of life and pregnancy status and parity were predominantly not significant.
Nearly half of the respondents (40.4%) preferred replacement of face-to-face consultations by video or telephone consultations, with half of the respondents preferring video consultation (50.7%).

Strengths and limitations
We measured the outcomes starting at the beginning of the COVID-19 pandemic in March 2020 over a period of almost two years, ending at the end of December 2021.The length of the study period, covering 22 months and four different COVID-19 waves, enabled us to discover trends in stress over time and during the evolution of the COVID-19 pandemic.Moreover, a large group of respondents was included in the survey.
A limitation typically encountered in surveys is a relatively low response rate.We reached a response rate of 55.2%.Since we did not include characteristics as educational level and medical history in our questionnaire, we are not able to adjust for selection bias.However, characteristics as age, pregnancy status, and geographical origin of the patients who filled out the evaluation questionnaire did not differ evidently with our previously published paper on blended periconception lifestyle care [14].The previous study contained all patients who received blended periconception lifestyle care (n ¼ 450), so we deem it unlikely that selection bias occurred in the current study [14].

Experienced stress
Previous studies reported major declines in the number of admissions to the emergency department [15,16], and the number of primary care visits [17], which are mostly attributed to stress and anxiety for the risk of contracting COVID-19 [10].Especially during the beginning of the COVID-19 pandemic, a considerable uncertainty about the consequences of a COVID-19 infection for pregnant women existed.In 2021, a systematic review concluded that a COVID-19 infection during pregnancy may be associated with increased risks of preeclampsia (OR 1.33, 95% CI 1.03 to 1.73), preterm birth (OR 1.82, 95% CI 1.38 to 2.39) [18], admittance to intensive care and intubation (RR, 5.04; 95% CI, 3.13-8.10),and other adverse pregnancy outcomes [19].Also, increasing evidence was reported for the potential detrimental effects of a SARS-CoV-2 infections for pregnant women by disruption of placental function [20].
A previous study on prenatal maternal stress during the COVID-19 pandemic, showed that 35% of the respondents is worried about being infected by the coronavirus [21].However, in the current study, only 7.8% of respondents experienced stress regarding their visit to the hospital and the risk of getting infected in the hospital with the SARS-CoV-2 virus.This might be explained by the fact that patients consider the chance of getting infected in the hospital as low, rather than that they are not afraid of the consequences of a SARS-CoV-2 infection for themselves and their pregnancy.The hospital implemented strict protective measures for health care professionals, and adapted medical facilities to ensure physical distancing.The complete set of protective measures might have increased the patient's perceived sense of safety when visiting the hospital.
The experienced stress among respondents in the current study was relatively low and also decreased over time.The sharper decline in stress in June 2020 might be due to the improved COVID-19 situation and relaxation of mitigation policies during the summer.In December 2020, the Dutch government announced the start of the global COVID-19 vaccination program, and thereby, could explain the decrease in experienced stress in December 2020.The increase in experienced stress during the end of 2021 on the other hand, has multiple reasons; the increasing evidence on the damaging effects of COVID-19 for maternal and fetal health, the exceptional increase in number of SARS-CoV-2 infections and hospitalized patients, and by the governmental imposed additional new strict lockdown measures.

Telemedicine
The current study showed that the majority of (pre)pregnant women would prefer the replacement of a face-to-face consultation with telemedicine, either a video or a telephone consultation.Moreover, this finding is not associated with stress caused by hospital visits or the risk to get infected, suggesting that telemedicine is a desirable innovation in health care, even after the COVID-19 pandemic.
According to the literature, telemedicine has several advantages, such as reduced transportation time and costs, no time in the waiting room or child care issues.The same arguments might underlie the preferred replacement of face-to-face consultations by video or telephone consultations.Moreover, (pre)pregnant women are relatively young and might be considered as a "digital generation" that is familiarized with digital information and communication technologies [22].Additionally, periconception lifestyle counseling is a health care service highly suitable for delivering by telemedicine modalities, like telephone or video consultation.In general, women prior to pregnancy or already pregnant are relatively young and healthy and are more likely to choose a telemedicine visit than male patients or patients of other ages, according to a recent study [23].
However, it should be acknowledged that 12.6% of the respondents in the current study did not want the face-to-face consultations to be replaced by video or telephone consultations.Thus, fully adopting telemedicine and replacing all face-to-face consultations of the periconception blended care approach by video or telephone consultations, will not meet the needs of all (pre)pregnant women.A better understanding of the underlying reasons for not wanting telemedicine could contribute to the process of shared-decision making, not relating to medical care, but regarding the way health care is consumed.

Conclusion
The COVID-19 pandemic has pushed health care over the technology tipping point and accelerated the adoption of telemedicine.These findings are useful for the wide implementation and integration of telemedicine within standard health care delivery, and reorganizing of periconception lifestyle health care toward personalized and more value-based health care, also after the COVID-19 pandemic.

Figure 2 .
Figure 2. Experienced stress on different aspects of life over time.
Figure Correlation matrix of experienced stress on different aspects of life.