MPPKI Media Publikasi Promosi Kesehatan Indonesia The Indonesian Journal of Health Promotion Pregnant Women's Quality of Life During the Covid-19 Pandemic: An Example from Makassar, Indonesia

Pregnancy is a period of considerable mental and physical changes that affect the quality of life, even without complications. During the Covid-19 pandemic, reports on maternity care services are still limited. This study aims to determine the effect of the Covid-19 pandemic on the physical and psychological health status of pregnant women. In addition, it also provides data on the potential risks of food insecurity that still exist, especially in developing countries. A total of 65 pregnant women participated in this study. The survey was distributed online via Google form during one month using convenience sampling (non-probability sampling) with a cross sectional design. Data was collected through two questionnaires, from World Health Organization Quality of Life (WHOQOL-BREF) and Consumption Behavior of Pregnant Women. The results showed that the respondents had a good quality of life (56.9%) as stated in the WHOQOL-BREF. Most of the respondents were in good category in terms of physical (90.8%), psychological (70.8%), social relations (61.5%), and environmental domains (90.8%). However, 4.6% were in the poor category in relation to the general quality of life. Regarding the perceived health status, about half of the respondents were satisfied with the individual's health during the pandemic, while 3.0% and 10.8% were highly satisfied and dissatisfied, respectively. It is recommended that pregnant women be screened for household food security status and quality of life during prenatal care which includes policy making, resource allocation, and appropriate service delivery with the aim of ensuring pregnant women's access to high quality food and a good quality of life.


BACKGROUND
The World Health Organization defines quality of life (QOL) as individual's perception of life in the context of the culture and value systems, and in relation to the goals, expectations, standards, and concerns (1). It is a very broad concept and can be influenced in a complex manner by the subject's physical health, psychological state and level of independence, as well as social relationships and important aspects of the environment (2). Therefore, quality of life is measured objectively in relation to environmental and living conditions, as well as subjectively in relation to personal environment, and measured in terms of satisfaction and well-being (3).
Pregnancy is a period of considerable mental and physical change which affects quality of life, even without any complications (3). These changes not only affects the mother, but also the baby postpartum health and psychomotor improvement (4). Therefore, health professionals in prenatal care increased patient health and satisfaction with regard to the experiences during preconception and pregnancy (5). Furthermore, the traditional use of objective measure such as mortality and morbidity were also employed (6). These measures are important, but not sufficient because public health services are not only limited to saving life, but to also improve personal satisfaction (7) (8).
During the Covid-19 pandemic, there were limited reports on pregnancy care because majority of the studies focused on the effect of Covid-19 infection on women. However, two systematic reviews were conducted on Covid-19 infection prevalence in pregnant women. Besides, in a recent systematic review, data from 108 pregnancies collected between 8 December 2019 and 1 April 2020, showed that three patients were admitted to the maternal emergency unit with no detailed maternal passings (9)(10). Meanwhile, one neonatal passing was recorded and six were admitted to the emergency unit. The apparently extreme pregnancy and neonatal confusions during the Coronavirus pandemic were majorly due to preterm birth and complexities of cesarean section (being the predominant option). Moreover, a new survey which covered an aggregate of 324 pregnant women with Coronavirus recorded seven maternal passings (11) (12).
Pregnant women in developed countries with efficient medical care frameworks suffer greatly from vulnerability to diseases which affects both the mother and child, meanwhile, nervousness caused by segregation and restricted quantities of birth chaperons are the major challenges in agricultural countries during the pandemic (13)(14)(15). Despite the lack of information, reports from a few countries show an increase in cases of abusive behavior in homes since the Coronavirus outbreak. For instance, the number of comparative cases reported to a police headquarters in Jingzhou, a city in China's Hubei Region, significantly increased in February 2020 compared to a similar period in the previous year (16). Therefore, this study aims to investigate pregnant women's quality of life during the Covid-19 pandemic in Makassar, Indonesia. There are limited evidence on the quality of life of women during Covid-19 pandemic and its relation to nutritional status. Meanwhile, these data are important because it provide evidence regarding health status of pregnant women both physically and psychologically. In addition, this study also provide data on the potential risk of food insecurity which still exist particularly in developing countries.

METHODS Participants
A total of 65 pregnant women participated in this study. This study and sampling is took one month to complete by convenience sampling (non-probability sampling). The survey was transferred and shared on Google during the online review stage. Meanwhile, reactions were saved simply by tapping on the "submit" button. The participants indicated individual intentions to partake in the investigation. Furthermore, the participants were requested to be honest in the responses. Aside the scale used to measure variables in this study, the sociodemographic data were also collected including maternal and gestational age, pregnancy characteristics, education level, marriage, occupation, consumption patterns and quality of life.

Data collection
This study was conducted using a cross-sectional design. Moreover, data were collected via two questionnaires, namely WHOQOL-BREF and Maternal Consumption behavior during pregnancy. In WHOQOL-BREF, the questionnaire was validated in two stages by two persons namely changing language translations and filtering word meanings to make participant understand the questions.

Location
The data were collected from several districts in the city of Makassar, South Sulawesi, Indonesia.

Data analysis
For the variables examined, descriptive statistics were calculated, and information was conveyed as n and percent for categorical variables. Furthermore, the association of food consumption with four domain of quality life variable was determined using Fisher's exact test. All measures were given a 0.05 significance level, and statistical analysis was done with SPSS.  Table 1 shows that majority of the respondents have BPJS type insurance (76.9%), normal BMI status (69.2%), do not use contraception (53.8%) and choose public health center as health facilities for pregnancy care (38.5%). In addition, regarding number of children, majority of the respondents had more than 2 (61.5%), while more than half are university graduates (55.4%) and homemaker (64.6%).

RESULTS
Regarding additional nutrition, 20% received supplemental food, while 61.5% and 52.3% consumed supplement and milk respectively. In terms of dietary intake, majority of the respondent consume plant (96.9%) and animal protein (93.8%). Moreover, majority also consume vegetable (84.6%) and fruit (87.7%), while 56.9% received tetanus toxoid.  Table 2 shows that majority of the respondents have good quality of life (56.9%) while 4.6% were in the bad category. Regarding the perceived health status, approximately half were satisfied with individual health during the pandemic, while 3.0% and 10.8% were very satisfied and unsatisfied respectively.  Table 3 shows quality of life in four domains as stated in WHO QOL-BREF. Majority of the respondent were in the good category in terms of physical (90.8%), psychological (70.8%), social relationship (61.5%) and environmental domain (90.8%).  Although in Tables 4 and 5 it does not show a significance of p<0.005. But in the physical domain that can be highlighted are those who consume health supplements, have a snacking habit, consume fruits and vegetables in the good physical category, around 90%. This is the same as the environmental domain, namely those who consume health supplements, have a snacking habit, consume fruits and vegetables and animal protein in the good category, around 90%. The Table 6 provides information of the five most consumption during pregnancy, snacks food listed biscuits about 60% as the highest, in vegetable category there is spinach as the majority consuming of 55% and animal protein is chicken 50% meanwhile the plant protein got two same type of food which are tofu and tempe about 40%.

DISCUSSION
Majority of the respondents have good quality of life (56.9%) as indicated in four domain of WHOQOL-BREF. Furthermore, majority were in good category in terms of physical (90.8%), psychological (70.8%), social relationship (61.5%) and environmental domain (90.8%) despite the imposed social distancing. The variable of social domain shows lower than the other variable due to the pandemic As a result, a remarkable condition emerged in which the vast majority of the world's population was confined to their houses, with only health workers and other critical employees permitted to go on a regular basis. Several investigations of prior quarantine events have found that physical and social seclusion can trigger psychological stress reactions (21). This distinction is important because a person can have the subjective experience of being isolated even when they have frequent contact with other people and conversely they may not feel isolated even when their contact with others is limited (22).
Adequate nutritional intake during pregnancy is an important factor for a healthy pregnancy and successful delivery (23). A previous study reported that nutritional deficiencies during gestation leads to provision of suboptimal micro and macro nutrients for the fetus, which culminates to inadequate intrauterine growth and development, congenital abnormalities, preterm birth, and pregnancy complications (23)(24)(25). The results in this study indicate that the nutritional behavior of pregnant women is significantly associated with healthier food choices, including frequent consumption of chicken, healthy vitamins and mineral supplements. This appears to be related to the education level of respondents which were mostly university graduates (55.4%) to choose healthy food particularly fruit, vegetables, supplements, milk and nuts such as tempe and tofu as well as other protein sources from fish and chicken meat. Meanwhile, this result is consistent with other studies which reported that highly educated people exhibit significantly better nutritional knowledge and consumption behavior (26)(27)(28)(29)(30). This is because highly educated people often make better use of educational materials such as newspapers, books, internet and academic resources in their daily lives. However, the results in this study show that there is no food insecurity in the respondents' food consumption, hence, the quality of life is generally in the good category.