*4.2. Results*

Existing literature has demonstrated linkage between disaster exposure and mental health [20]. Studies showed that people exposed to natural disasters, including hurricanes, floods and earthquakes or specific collective traumatic events such as wars, may have series threat to mental health, with those who had higher exposure having greater rates of mental disorder [20,21]. Adverse mental health outcomes include particularly post-traumatic stress disorder, depression, or anxiety, including major depressive disorder and generalized anxiety disorder. In addition, health-related problems, such as somatic complaints, sleep disturbances, and substance abuse were reported among survivors of collective disasters [20–22].

Women are more vulnerable to disaster-related psychopathology than men [23–25]. Female gender has generally been associated with reduced resilience after disaster, but greater post-traumatic growth. After the Madrid train bombing, women reported more post-traumatic growth and positive changes, but also more negative changes and associated depression and anxiety [25].

Pregnant and post-partum women may be vulnerable to post-disaster psychopathology, and their mental health is of particular concern, because of their special role in taking care of their children and families [25]. Unplanned pregnancy, being multiparous and a poor marital relationship were associated with worse pregnancy mental health [23], while having support from the partner and family were protective [26,27]. Nevertheless, in our population, marital status was comparable between the groups.

Few studies, conducted world-wide following disasters, investigated the psychiatric morbidity of pregnant and post-partum women in the disaster areas. Khatry et al. examined the influence of the 2015 Nepal earthquake on pregnant women at the time. By using the EDPS score, they assessed clinically-significant symptoms of antenatal common mental disorders, their risks and protective factors. They found that pregnant women who experienced the earthquake had higher risk for clinically significant mental disorders. Women with greater vulnerability were those who lack intimate partner relationship, had prior pregnancy losses and who lack income-generating work [26].

Chang et al. examined the influence of Taiwan 921 earthquake on mental health in a group of women from Pu-LI, a town a few kilometers from the epicenter, who were pregnant during or immediately after the major earthquake disaster. The prevalence of minor psychiatric morbidity found was high, 29.2% of all women examined, with a positive correlation to post-traumatic stress disorder. A risk factor for psychiatric morbidity was spouse causality [27].

On the contrary, overall rates of depression and posttraumatic stress disorder were not significantly higher among groups of postpartum women from southern Louisiana who were pregnant during or shortly after the Hurricane Katrina [23]. In their next study, the authors demonstrated that, not only were the pregnant and post-partum women more resilient to the consequences of the disaster, they also grew and perceived benefits after the disaster [25].

Engel et al. investigated the consequences of the destruction of the World Trade Center on 11 September 2001 on the health of pregnant women and their fetuses. They enrolled women who were pregnant and living or working within close proximity to the disaster. They found that post-traumatic stress symptomatology and moderate depression were associated with long gestational duration [24].

As can be seen in other related studies, poor marital relationship was associated with worse pregnancy mental health [23], while having support from the partner and family were protective [26,27]. Our study failed to find such as association. This may be explained by the size of the cohort, or by the fact that our study assessed risk for depression by the EDPS questionnaire and not a diagnosis of depression. Results may have been different if we would have repeated the study few of months after delivery.

While most of the previous studies investigated post- disaster depression, our study investigated risk for depression during the COVID-19 pandemic. Mounder et al. investigated mental health response among health care workers during the first 4 weeks of the SARS outbreak in Toronto, Canada. The authors found that the most prominent emotional effects were fear, loneliness, boredom, anger, and worry about the effect of quarantine and contagion; they experienced the psychological effect of physical symptoms [5].

### *4.3. Clinical Implications*

Our study demonstrated comparable rates of depression among women hospitalized in the high-risk pregnancy units during and before the COVID-19 pandemic. There are several possible explanations for this association. First, as was noted previously, many people, and especially pregnant and postpartum women, are resilient after terrible events, and may experience various forms of benefits [25]. Posttraumatic benefit relates to posttraumatic growth going beyond baseline to an improved state of functioning after trauma. Such growth is described as changed priorities, having a greater appreciation of life, an increased sense of strength, self-reliance, expressiveness, compassion, and improved relationships. Second, Harville et al. determined that greater experience of the disaster was associated with less resilience [25]. Resilience is the ability to overcome difficulties and stressors, and does not mean being completely unaffected by terrible events or not having limited periods of mental health problems. It is heavily influence by how closely the disaster personally affected them. Our study population did not have any patients with a proven infection with SARS-COV-2, which may be related to the pandemic self-experience of the women and their mental consequences enrolled in our study. The same group also demonstrated that mental health problems following forces on the general population might be even lower in post-partum women, possibly because of more social

support and nurturing after difficult circumstances [23]. This may also explain the comparable rates of depression between the study groups. Bonnano et al. examined the prevalence of resilience among a large group of New York area residents during the six months following the 11 September terrorist attack, demonstrated that even among the groups with the most pernicious levels of exposure and highest rates of post-traumatic stress disorder, the proportion that were resilient never dropped below one third [28]. This may explain our findings of comparable depression rates between women during and before the pandemic, with a substantial percentage of the exposed women who demonstrated resilience. Finally, the EDPS questionnaire is a rather screening then diagnostic test, hence false negative results may occur. In addition, depression may evolve months after filling the questionnaire.
