Pregnancy in itself triggers anxiety in women, but during the coronavirus disease 2019 (COVID-19) pandemic, stress levels increased due to changing circumstances, adjusting to constraints, and unpredictability [1]. The virus spread rapidly and there was little information about its effects on pregnancy and the fetus. Public health recommendations changed daily and impacted social life enormously. Routine pregnancy examinations were reduced, the presence of the partner at examinations and during labor was restricted or even prohibited, and postpartum visits were abolished. Health care workers wore protective equipment that did not help create a home-like atmosphere, which is emphasized as an element of a relaxed environment for childbirth. All of these factors added stress to pregnant women.

The study approach was based on quantitative research. A descriptive and causal non-experimental empirical research method was used [28].

The aim of the study was to find out what level of stress pregnant women in Slovenia experience in relation to the COVID-19 pandemic and whether our results are comparable to those of other countries. The study contributes to filling a gap related to the issue of social importance, namely women’s perception of stress during a pandemic. We also aimed to find out in which areas Slovenian pregnant women experienced higher levels of stress due to the COVID-19 pandemic. We hypothesized 4 outcomes (H).

H1: One-third of participants would estimate their level of stress as high and caused by the COVID-19 pandemic.

H2: Pregnant women in Slovenia experienced the highest level of stress during the COVID-19 pandemic due to concerns about infection.

H3: The results of a survey on the stress experience of pregnant women in Slovenia during the COVID-19 pandemic will be consistent with the results of surveys conducted in the USA and Germany [5, 18].

H4: During the pandemic, those who were pregnant for the first time, had a high-risk pregnancy, experienced income loss, were in their second or third trimester, and those who had already recovered from COVID-19 experienced higher levels of stress.

The research instrument used was a validated questionnaire—PREPS [5]. We obtained permission to use it in our study.

The results are presented according to the hypotheses. For H1 (one-third of participants estimated that they were exposed to a high level of stress during the pandemic due to COVID-19), the criterion for a high level of stress was established when women marked the statements “agree” or “strongly agree”. As shown in Table 2, 64.5% of pregnant women who participated in the study agreed or strongly agreed with the statement “I am concerned that COVID-19 infection may affect my pregnancy”. The second statement, “I am worried that COVID-19 infection could harm my baby”, was agreed or strongly agreed by 71.9% of participants. The third statement, “I am worried that I could become infected with COVID-19 when I go to the hospital for delivery”, was agreed or strongly agreed by 41.9% of respondents.

The fourth statement, “I worry about my baby being infected with COVID-19 in the hospital after birth” was agreed or fully agreed by 54.2%, and the last statement, “I worry about having to go to prenatal care appointments because of COVID-19”, was agreed or fully agreed by 39.8% of participants. The highest stressor for participants was the fear that infection with COVID-19 would harm their pregnancy or unborn child.

Table 3 presents the results on self-assessed stress levels related to childbirth preparation. This stress category was measured by 7 statements. As can be seen, 47.9% of participants agreed or strongly agreed with the statement “I worry that people won’t be able to help me take care of my baby after birth”. The second statement, “I worry that I’ll be separated from my baby after delivery because of the pandemic”, was agreed to by 47.3%, and the third statement, “I worry that the pandemic will ruin my birth plans”, was agreed to by 42.8% of pregnant women.

The fourth statement, “I worry that I will not be prepared for childbirth because of pandemic restrictions”, was agreed or strongly agreed by 31.2%. The fifth statement, “I worry that I will not get enough healthy food, sleep, or exercise because of COVID-19 restrictions”, was agreed or strongly agreed by 19.8%. The sixth statement, “I worry that I will not be able to have anyone with me during childbirth”, was agreed or strongly agreed by 88.1% of participants. The last statement, “I worry that I will not get the prenatal care I need because of COVID-19”, was agreed or strongly agreed with by 51.8% of pregnant women. The greatest concern appeared to be that their partner would not be able to attend the birth and that they would not receive adequate care because of the pandemic (Table 3).

Table 4 presents the results of three statements that measured positive stress. High stress was considered a disagreement with the statements here. The first statement, “I think that the thought of having a baby will help me overcome the difficulties of the pandemic”, was disagreed with by 26.5% of respondents. The statement, “I feel that pregnancy gives me strength during the pandemic”, was disagreed with by 38.7%, and the statement, “I feel that COVID-19 helps me appreciate my pregnancy more”, was disagreed to by 57.7% of respondents.

We divided our H1 into 15 subhypotheses-separately for each statement (data for the first five are in Table 2, the next seven in Table 3, and the last three subhypotheses in Table 4). For 10 out of 12 sub-hypotheses, the sum of agreeing and strongly agreeing responses is more than one third—33.33%. In the case of positive stress measurements, 2 out of 3 sub-hypotheses reached more than one third (33.33%). Therefore, we can confirm H1.

To confirm H2 (pregnant women in Slovenia experienced the highest level of stress due to concern about infection during the COVID-19 pandemic), the criteria were a higher proportion of perceived stress. Table 5 presents the results of self-assessments of stress in relation to COVID-19 in different dimensions as in PREPS. The highest level of stress was perceived in relation to fear of infection with COVID-19; 54.46% of participants rated this type of stress as 4 or 5. Stress in relation to preparation for childbirth ranked second (47%). In the dimension of positive stress, only 41% of participants rated their own stress level as 4 and 5.

H2 was confirmed because the results showed that women felt the highest levels of stress due to concern about COVID-19 infection (strongest agreement with statements measuring this dimension).

To test H3 (results of a survey of stress experienced by pregnant women in Slovenia during the COVID-19 pandemic are consistent with the results of surveys conducted in the USA and Germany), Fig. 1 was prepared comparing the results of our study, the USA study [5] and the German study [18]. These two studies were the only ones that used PREPS as a research tool. The Italian study and the study in Poland that used PREPS focused more on validating the instrument than on reporting research findings.

All of the studies shown in Fig. 1 involved more than 1000 pregnant women. The results are relatively consistent. Both the USA and Slovenian studies reported the highest level of stress in the fear of perinatal infection category (29.1% of participants in USA and 27.23% in Slovenia rated infection stress high). In contrast, pregnant women in Germany rated stress with regard to birth preparation higher (16% of women rated stress with regard to birth preparation as very high, while infection stress was rated high by only 12%). The average estimate in the preparedness stress dimension ranged from 3 to 4 in all studies, whereas estimates in the infection stress dimension ranged from 2 to 3.

Women in all countries were least likely to agree with statements about positive stress, with the most common estimate being less than 2 (34.4% in USA sample, 48% in the German sample, and 17.9% in the Slovenian sample).

Fig. 1 shows factors that affect higher levels of stress. In all studies, primiparous women, those in their second or third trimester, and those who believed they had had COVID-19 infection but it was never medically confirmed felt higher levels of stress related to birth preparation. In the Slovenian study, women who had been previously treated for infertility, had a high-risk pregnancy, or experienced income loss during the pandemic also felt higher levels of stress.

Factors that influenced infection stress varied by country. In the USA, second-trimester, those who had experienced income loss during the pandemic and those who believed they had COVID-19 but were not medically confirmed, experienced higher levels of stress. In Germany, scores were higher among first-time mothers and women in the first or second trimester, whereas in Slovenia the risk factors were parity (first pregnancy), income loss, high-risk pregnancy, and belief of previous infection with COVID-19 (that was not confirmed). In all countries, higher levels of positive stress were associated with primiparity and income loss.

In general, Slovenian results were similar to the studies from all three countries, allowing us to confirm H3.

Tables 6,7 present the results related to H4 (during the COVID-19 pandemic, those who were pregnant for the first time, had a high-risk pregnancy, experienced income loss, were in the second or third trimester, and those who had already recovered from COVID-19 had higher stress levels). One criterion for confirming H4 was higher mean scores when comparing variables. Table 6 shows the mean scores and standard deviations of self-assessed stress in all PREPS dimensions.

Table 7 shows a comparison of the mean values with respect to the factors: parity, duration of pregnancy, previous infection with COVID-19, income loss during the pandemic, and course of pregnancy (normal/high-risk).

First, we compared averages by parity. The majority of participants were pregnant for the first time (61.9%), 30.7% were pregnant for the second time, and 7.4% were pregnant for the third time. No major differences were found between these groups in terms of stress perception. A slight difference was seen in stress scores related to preparation for childbirth, where first-time mothers had a mean score of 3.183 and third-time mothers had a slightly lower mean score of 3.067.

The second comparison was made according to the trimester of pregnancy. The majority of participants were in the 3rd trimester (52.3%), 38% were in the 2nd trimester, and 9.7% were in the 1st trimester. The highest ($\overline{x}$ = 3.2) stress scores related to prenatal care were reported by women in the third trimester, especially in the infection stress dimension.

We also compared the results according to the course of pregnancy-normal or high-risk. Few participants (13.1%) reported a high-risk pregnancy, but they reported higher stress levels ($\overline{x}$ = 3.5) on the dimension of being prepared for birth and even higher stress levels ($\overline{x}$ = 3.612) on the dimension of fear of infection.

We also compared stress levels between those who had lost their income during pregnancy (15%) and others who had not. Pregnant women who had lost their jobs reported higher rates of stress related to fear of infection ($\overline{x}$ = 3.46) and also higher rates of stress related to being prepared for childbirth ($\overline{x}$ = 3.59) compared with the group who had not lost income (infection stress $\overline{x}$ = 3.38 and preparation for birth stress $\overline{x}$ = 3.11). Positive stress scores also differed. Surprisingly, pregnant women who experienced income loss had higher levels of positive stress ($\overline{x}$ = 3.001) compared with the others ($\overline{x}$ = 2.82).

Finally, we compared the responses of those who had COVID-19 infection in the past (32.3%), those who thought they had it (13.7%), and those who did not experienced infection by the time of the study (54%). Overall stress was highest among those who only believed they had an infection ($\overline{x}$ = 3.356); however, the infection stress dimension was highest among women who had not yet had an infection ($\overline{x}$ = 3.410).

Five items were reviewed in relation to H4. According to the mean scores, we can confirm only four of them. The data show that those who were suspected of having COVID-19 infection in the past but did not have it confirmed felt more stress. Therefore, we can only partially confirm H4.

With this study, we confirmed that pregnant women were exposed to high levels of stress during the COVID-19 pandemic. Their greatest concern was that the infection would harm their pregnancy and unborn child. They also feared that they would not be properly prepared for delivery, that their partner would not be present during delivery, and that their baby would be taken away from them during hospitalization or that they would both become infected with COVID-19. Similar results have been found in other studies [5, 18, 26, 27]. In particular, first-time mothers and mothers at the end of pregnancy experienced more stress than others. This suggests that it is important to address and manage stress during difficult times. Some of their fears were justified. Childbirth preparation courses, which provide a foundation for preparing for labor and delivery, were offered online during the pandemic. Despite some advantages of online courses, there are also a number of disadvantages (Internet access might not be available for all, less opportunity to practice, lack of individual counseling, shyness to ask questions in the presence of other couples) [23]. Some authors suggested individual counseling sessions [23], but this was hardly possible during the pandemic due to staff shortages. The overwhelming amount of information and advice available on the internet may also contribute to stress. It can be challenging to sort through conflicting information if you are pregnant for a first time and have little experience.

Many concerns relate to the hospital situation and therefore some women considered the option of home birth. Some countries reported a higher proportion of home births during the pandemic [35], including Slovenia [36]. This way, women were less afraid of their baby getting an infection or being separated from the baby in the postpartum period, and their partner could be present during labor and delivery. It is understandable that high-risk pregnant women were more stressed because a home birth was not an option for them. Their concerns might be related to a possible worsening of risks in the event of infection with COVID-19.

Almost half (46%) of pregnant women were in stress due to fear of COVID-19 infection. Moyer et al. [37] reported even higher rates (93%) in their study, likely because they conducted their study at the beginning of the pandemic when little was known about the virus and health protocols were changing almost daily. The media reported higher rates of pregnant women requiring mechanical ventilation than the rest of the population, and they reported the presence of the virus in amniotic fluid. No one could reassure the pregnant women, and this uncertainty caused great anxiety. Even after the vaccine was introduced, uncertainty remained. Some doubted its safety and questioned long-term side effects because the vaccine had been developed quickly. Doubts were even greater among pregnant women because pregnant subjects were excluded from the safety studies [38]. As the due date approached, mothers may have increased anxiety about labor and delivery. The pandemic may exacerbate these concerns because of the unpredictability of hospital policies, fear of being infected by the virus in health care settings, and restrictions on presence of partners at birth.

Perhaps it was this uncertainty that led to high stress levels in most women who only believed they had overcome the infection (COVID-19) but were never medically diagnosed. Preis et al. [5] also reached the same conclusions in their study in the USA. However, their study was conducted at a time when routine testing did not exist, whereas our study was conducted later.

As in other studies [5, 18] along with ours, higher stress levels were associated with greater gestational age, primiparity, and income loss. This confirms that the impact of the pandemic was global and multidimensional, as other researchers have also noted [19].

Primigravid patients are said to feel more stress even without the pandemic, but the circumstances of COVID-19 exacerbated these tensions [38]. Worries about childbirth also increased because they did not have the opportunity to visit the maternity hospital and meet the medical staff before delivery. Some maternity hospitals have created videos for virtual delivery room visits in response to women’s needs, but this cannot replace the in-person visit.

Pregnancy raises numerous concerns, including financial ones, as additional expenses are expected. The pandemic has reduced people’s overall financial security. In Johnson’s study [39], more than one-third of women lost their job during this period. In our sample, 15% of participants lost income during pandemic COVID-19. Similar results were found in other studies [5, 18, 26, 27, 40, 41, 42, 43, 44]. Financial worries only contributed to higher stress levels. Surprisingly, women who lost income during the pandemic reported the highest levels of positive stress in our study. Apparently, they found comfort in pregnancy and the thought of having a child.

We expected Slovenian women would experience higher levels of stress during the pandemic as in the USA study, since policymakers and health authorities communicated pandemic restrictions to the Slovenian public in an authoritative manner. However not many differences were found in stress levels. It would be interesting to compare perceived stress of pregnant women with PREPS during the time of pandemic from Scandinavian countries, where policy makers used more soft approaches, i.e., they gave recommendations instead of restrictions.

We believe that all people were stressed during the pandemic, but pregnant women are an especially vulnerable group whose stress could also have an impact on their babies. Our findings can be used to advocate for policy changes and provide resources to address various health challenges caused by any future pandemic.

All data points generated or analyzed during this study are included in this article and there are no further underlying data necessary to reproduce the results.

APM, EG, AJD: conceptualisation and wrote the paper, designed the analysis, collected the data, contributed in analysis. APM, AJD: edited the article and undertaken a critical review and revision – including all stages of publication. All authors have read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was conducted in accordance with the Helsinki-Tokyo Declaration. All participants were assured that the data collected would be used for research and publication purposes. Their participation in the study was voluntary. They also provided written informed consent to participate in the study. The study was approved by the Departmental Faculty Ethics committee (approval number: 3/15_6_2022).

We would like to thank all the participants who participated in the study.

This research received no external funding.

The authors declare no conflict of interest.