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 Table of Contents  
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 27-32

The effect of risk perception and COVID-19 anxiety in pregnancy on decision-making via the Internet and prenatal care quality: A cross-sectional multivariate analysis

1 Obstetrics and Gynecology Nursing, Faculty of Health Sciences, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
2 Department of Nursing, Balıklıgöl State Hospital, Sanliurfa, Turkey

Date of Submission31-May-2022
Date of Decision20-Dec-2022
Date of Acceptance21-Dec-2022
Date of Web Publication23-Mar-2023

Correspondence Address:
Ayse Tastekin Ouyaba
Afyonkarahisar Health Sciences University, Zafer Saglik Kampüsü, Dörtyol Mah. 2078 Sok. No: 3, 03200, Afyonkarahisar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jin.jin_52_22

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Background: Risk perception and COVID-19 anxiety in pregnant women restrict access to health services, cause pregnant women to resort to alternative channels such as the Internet, and affect prenatal care quality (PCQ) negatively.
Purpose: The purpose of this study was to examine the effect of risk perception and COVID-19 anxiety in pregnancy on decision-making via the Internet (DMI) and PCQ with multivariate analysis.
Materials and Methods: This cross-sectional study was conducted with 406 pregnant women selected using the convenience sampling method in a training and research hospital, in Turkey. The data were collected using the information form, the perception of pregnancy risk questionnaire, the Coronavirus Anxiety Scale, the DMI Scale, and the PCQ Scale. The data obtained were subject to descriptive analysis and the multivariate analysis of variance.
Results: Approximately 24.9% of the pregnant women were found to have a high perception of risk and 18% had symptoms of COVID-19 anxiety. Pregnant women with high COVID-19 anxiety and a higher perception of risk perceived the Internet as less influential for decision-making (P < 0.05). Pregnant women with a high-risk perception had lower PCQ (P < 0.05).
Conclusion: The findings can be used to enhance mental health and resilience in pregnant women and to formulate appropriate intervention strategies.

Keywords: COVID-19 anxiety, decision-making via the Internet, perception of risk, pregnancy, prenatal care quality

How to cite this article:
Ouyaba AT, Taskin S. The effect of risk perception and COVID-19 anxiety in pregnancy on decision-making via the Internet and prenatal care quality: A cross-sectional multivariate analysis. J Integr Nurs 2023;5:27-32

How to cite this URL:
Ouyaba AT, Taskin S. The effect of risk perception and COVID-19 anxiety in pregnancy on decision-making via the Internet and prenatal care quality: A cross-sectional multivariate analysis. J Integr Nurs [serial online] 2023 [cited 2023 May 28];5:27-32. Available from: https://www.journalin.org/text.asp?2023/5/1/27/372415

  Introduction Top

During the COVID-19 pandemic, pregnant women were defined as a vulnerable group and were advised to take additional precautions.[1] Susceptibility to the disease,[2] physiological changes, and maternal/fetal risks during pregnancy increase the risk perception of the disease in pregnant women.[3],[4] The perception of high risk during pregnancy causes an increase in mental health problems such as stress and anxiety.[5] However, pregnant women feel uncertain about consulting a health center due to the potential risk of infection in the COVID-19 process. A study conducted in China revealed that approximately 94.6% of pregnant women were worried about being infected with COVID-19.[6] In another study conducted in China, it was reported that 41.9% refused to go to the hospital for prenatal care.[7] Studies examining whether COVID-19 affects the plans, decisions, and prenatal care quality (PCQ) of pregnant women are extremely limited. Liu et al.[8] determined that COVID-19 increased the anxiety levels of Chinese pregnant women, affecting their decision-making processes on issues such as hospital preference, antenatal care, delivery time, and mode of delivery. Cancellation of antenatal appointments and changes in birth plans were associated with an increased likelihood of clinically higher depression, anxiety, and/or pregnancy-related anxiety symptoms in Canadian pregnant women.[9] In a study conducted in Sri Lanka, it was reported that 69.3% of pregnant women missed at least one antenatal care, and 24.2% had difficulty traveling for health care and received inadequate prenatal care.[10] Akyıldız determined that 77.6% of pregnant women are worried about contracting COVID-19, 70% of them are worried about transmitting the infection to their baby, and these women receive less prenatal care.[11]

The United Nations Population Fund has prepared a protocol that combines telehealth facilities (phone or video chat) to ensure that there are no disruptions or malfunctions in prenatal care services during the COVID-19 process.[12] Although prenatal care services continue during the pandemic in Turkey as in the world, it has been recommended to shorten the time pregnant women spend in health institutions, not to be called to the health institution except for prenatal follow-up (blood pressure measurements, weight measurements, fundal height measurements, auscultation of fetal heart tones, etc.), and to conduct online childbirth classes to reduce the risk of COVID-19.[13] The Internet can be used as a potential source of prenatal care, as pregnant women mostly prefer mobile health applications and online consultations.[6],[7]

Nurses, who are the world's most trusted health-care professionals during the COVID-19 pandemic, are in an ideal position to integrate prenatal care into today's changing conditions, focusing on the unique needs of the mother and baby.[14] Furthermore, during the pandemic, the collection of data on prenatal care in pregnancy can shed light on the areas where these services are affected.[15] The study aims to examine the effect of risk perception and COVID-19 anxiety in pregnancy on decision-making via the Internet (DMI) and PCQ. The research hypotheses are H1: Perception of risk affects DMI, H2: Perception of risk affects PCQ, H3: COVID-19 anxiety affects DMI, and H4: COVID-19 anxiety affects PCQ.

  Materials and Methods Top

Study design and setting

This cross-sectional multivariate analysis was conducted with the pregnant women who consulted for prenatal care at the Obstetrics and Gynaecology Outpatient Clinic of Şanlıurfa Eyyübiye Training and Research Hospital, Turkey.


In 2020, around 25,000 pregnant women visited this hospital. The sample size for this target population was calculated as 382 with 95% confidence and a 5% error margin.[16]

The pregnant women who were between the ages of 18 and 49 years, who did not have speech and comprehension disabilities, who were able to speak and read Turkish, who had Internet access, and who agreed to participate were included in the study. The exclusion criteria were being a foreign national, having left some questions in the scales unanswered, having high-risk pregnancies, and having a mental health problem. The study was conducted with 406 pregnant women selected with the convenience sample method.

Study tool and data collection

The data were collected using a questionnaire consisting of 24 questions related to the sociodemographic, gynecological, obstetric characteristics, and Internet use of pregnant women, and the following scales.

The perception of pregnancy risk questionnaire

The questionnaire was developed by Heaman and Gupton to evaluate the current risk perception of pregnant women. It is a visual analog measurement tool consisting of nine items and two subdimensions: perception of risk for self and perception of risk for the baby. Each item is scored between 0 (no risk) and 100 (extremely high risk) using a 100 mm linear line. A high mean score of the items indicates a high-risk perception of the pregnant woman. Since the scale does not have a cutoff point, the score corresponding to 75% was considered the cutoff point in this study. The cutoff points were determined as the perception of risk ≥18.38. The Cronbach's alpha was 0.87 in the original scale,[17] 0.84 in the Turkish adaptation study,[4] and 0.77 in this study.

Coronavirus Anxiety Scale

The scale was developed by Lee[18] to assess the symptoms of coronaphobia (fear and anxiety caused by exposure to thoughts or information about the coronavirus) as five-item scale with one dimension. Each item is rated between 0 (not at all) and 4 (nearly every day over the past 2 weeks). The cutoff score of the scale for general population surveys is ≥5. As the scale score increases, the symptoms of coronavirus anxiety (CA) increase.[19] The Cronbach's alpha was 0.93 in the original scale,[18] 0.80 in the Turkish adaptation study,[20] and 0.60 in this study.

Decision-making via the Internet scale

The scale was developed by Koyun and Erbektaş to evaluate the relation of the Internet to decision-making during pregnancy. The scale consists of 10 items, for example, “The Internet allows me to be involved in decision-making about pregnancy” and “The Internet gives me control over decisions that affect my pregnancy.” Each item is rated on a scale from 1 (I totally disagree) to 5 (I totally agree). Higher scores on the scale indicate that the Internet is more influential in the decisions taken by pregnant women. The Cronbach's alpha of the original scale was 0.85[21] and 0.90 in this study.

Prenatal care quality

PCQ in the last prenatal follow-up of pregnant women was evaluated by giving 1 point for each of the following six criteria in the study of Ergin et al.[22] Immunization against tetanus, weight measurement, hemoglobin measurement, blood pressure measurement, listening to the baby's heartbeat, and using iron pills. In the present study, in addition to the above criteria, ultrasound and vaginal examination were also questioned, and PCQ was evaluated with eight criteria. The score corresponding to 25% was considered the cutoff point in our study. If the total score was ≤4, the PCQ was considered poor.[22] The Kuder–Richardson (KR-20) coefficient of the scale was 0.66 in this study.

Data collection tools were applied to pregnant women who met the inclusion criteria in an empty room in the outpatient clinic between February and July 2021. The data collection process took approximately 15–20 min.

Statistical analysis

Descriptive statistics of the data were calculated. The effect of risk perception and COVID-19 anxiety in pregnancy on DMI and PCQ was investigated using the multivariate analysis of variance (MANOVA). MANOVA was used to evaluate the data. The equality of variances was examined with Levene's test. After deleting the outliers (n = 18), the remaining data (n = 382) were found to fit the normal distribution. The equality of multiple variance–covariance matrices was checked with Box's M test. A probability distribution was evaluated with Wilks' lambda. The Bonferroni correction was used in multiple comparisons. The effect of main effects on the output variables was analyzed with partial eta squared (ηp2). The SPSS Statistic 25 program (IMB SPSS Statistics, Chicago, IL, USA) was used for statistical analysis, and the significance level was set at P < 0.05.

Ethical considerations

Approval for the study was obtained from the institution where the study was conducted and the Clinical Research Ethics Committee of Harran University (numbered HRU/21.04.30 and dated February 15, 2021). After explaining the aim of the study, we applied a questionnaire to the women who voluntarily agreed to participate in the study.

  Results Top

Sociodemographic, gynecological, obstetric, and Internet usage characteristics of 406 pregnant women are given in [Table 1]. Approximately 26.3% of the pregnant women were high school graduates and 55.7% of them had moderate or better economic status. Approximately 44.8% of the pregnant women had a complaint during their pregnancy and 45.3% had difficulty going to the hospital for prenatal care during the pandemic period. The main source of information for pregnant women was health personnel (60.1%). About 24.9% of the pregnant women had a high-risk perception and 18% had symptoms of CA [Table 1]. The mean age of the pregnant women was 28.22 ± 6.41 years, the mean number of living children was 2.06 ± 1.83, the mean gestational week was 27.43 ± 9.74, the mean number of prenatal visits was 9.54 ± 6.05, and the daily Internet usage time was 3.04 ± 2.14 h. Correlations between variables ranged from -0.29 to 0.49 [Table 2].
Table 1: Sociodemographic and pregnancy-related characteristics of women (n=406)

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Table 2: Correlations between some variables (n=406)

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Before the MANOVA analysis, it was tested whether the assumptions were met. Equality of multiple variance–covariance matrices (P = 0.243, F = 1.278, Box's M = 11.736) and variances were met (Levene test, P > 0.05). Perception of risk (P ≤ 0.001, F = 11.062, Wilks' lambda = 0.945) and COVID-19 anxiety (P = 0.018, F = 4.076, Wilks' lambda = 0.979) were a significant relationship with the dependent variables.

The results of the MANOVA analysis are presented in [Table 3] and [Table 4] and [Figure 1]. According to this, pregnant women with a higher perception of risk and high COVID-19 anxiety perceived the Internet as less influential for decision-making (P < 0.05; H1 and H3 were accepted). Perception of high risk negatively affected the PCQ (P < 0.05; H2 accepted), and the effect of COVID-19 anxiety was not significant (P > 0.05; H4 was rejected).
Table 3: Multivariate analysis of variance results (n=382)

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Table 4: The multiple comparisons of scale scores (n=382)

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Figure 1: Multiple comparisons of scale scores. (a) The effect of the perception of risk and COVID-19 anxiety on DMI. (b) The effect of the perception of risk and COVID-19 anxiety on PCQ. DMI: Decision-making via the Internet, PCQ: Prenatal care quality

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  Discussion Top

The current COVID-19 pandemic continues to affect vulnerable pregnant women unequally. In addition to the problems perceived by the general population during the pandemic, pregnant women suffered from the inability to meet their specific needs related to pregnancy, birth, and postpartum periods.[23] Increasing the quality of care for the improvement of health is the responsibility of nurses.[24] Evaluating the effect of risk perception and COVID-19 anxiety on PCQ in pregnant women is important in terms of developing new health protocols suitable for today's conditions.[25] Our study presents new findings on the effect of risk perception and COVID-19 anxiety in pregnancy on DMI and PCQ. The findings can also be used to enhance mental health and resilience in pregnant women and to formulate appropriate intervention strategies during the COVID-19 pandemic.

During the pandemic, risk perception during pregnancy has been an important predictor of protective behaviors.[26] However, little is known about how COVID-19 anxiety and risk perception affects the plans and decisions of pregnant women.[25] Our study revealed that one out of every four pregnant women had a high perception of risk. In addition, in our study, it was found that pregnant women with high COVID-19 anxiety and risk perception use the Internet less to make pregnancy-related decisions. This result may have been caused by the fact that pregnant women with high-risk perception and COVID-19 anxiety did not trust the information on the Internet due to speculative news and information pollution, or they received help from other sources. Indeed, some governments and organizations have proposed remote (virtual) prenatal care appointments with doctors and obstetricians and/or meetings with limited face-to-face care teams, whenever possible in the COVID-19 process.[12],[13],[27] Similarly, in the United States, it was determined that the most common relation of COVID-19 on pregnant women was reducing the frequency of face-to-face visits by health-care professionals in favor of online visits and telephone calls.[28]

Cancellation of prenatal appointments and changes in pregnancy-related plans may negatively affect PCQ during the pandemic.[9] As it is known, the COVID-19 pandemic causes concerns about contracting COVID-19 in the hospital.[29] Our results show that during the pandemic period, 45.3% of pregnant women had difficulty going to the hospital for prenatal care, and approximately one out of every five pregnant women experienced COVID-19 anxiety. In addition, PCQ decreased as the perception of risk of a pregnant woman increased. Perhaps, pregnant women with a high perception of risk may have postponed or canceled face-to-face antenatal care appointments due to difficulties in accessing care, strategies to cope with pandemic stress,[30] negative experiences in the past, and fear of unknown pregnancy outcomes.[31] Similarly, in some studies conducted in the USA, it has been determined that pregnant women with high COVID-19 anxiety use video conferencing and phone calls and do not attend prenatal face-to-face appointments.[32],[33]


This study has some limitations. The first limitation is related to the design of the study and the sample size. Furthermore, the generalizability of these findings may be limited due to the exceptional nature of the COVID-19 pandemic, which has brought unique changes to patient care. Second, since a self-report tool was used to collect data in the study, the data were based on participants' statements and were not clinically validated.

  Conclusion Top

The results of this study showed that pregnant women with high COVID-19 anxiety and high-risk perception use the Internet less in decision-making, and PCQ is lower in pregnant women with high-risk perception for the baby. The findings can be used to enhance mental health and resilience in pregnant women and to formulate appropriate intervention strategies during the COVID-19 pandemic.

Nurses must integrate prenatal care into today's changing conditions, focusing on the unique needs of mothers and babies. During the pandemic period, increasing anxiety disorder during pregnancy should be paid attention and necessary psychological support should be provided. Nurses should implement interventions that reduce the risk perception and COVID-19 anxiety of pregnant women and increase PCQ and should test the effectiveness of these interventions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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