During pregnancy, women undergo unique physiological, psychological, and social changes. They are exposed to a considerable amount of visible and potential stress, which can make them more susceptible to depression and anxiety [1]. Before the outbreak of the coronavirus disease 2019 (COVID-19) prenatal stress, encompassing general worries and fears about pregnancy, was reported as being more prevalent among pregnant women with a history of mental illness, those who were younger, or those with lower incomes and educational levels [2]. However, during the COVID-19 pandemic, even pregnant women without these risk factors appeared to have experienced high levels of prenatal stress, and some exhibited symptoms of dissociative disorder and posttraumatic stress disorder (PTSD) [2] . There was also a significant increase in depression and anxiety disorders during the pandemic, which indicates that the psychological impact of the pandemic appeared to have been a threat to all pregnant women, not just those with vulnerable characteristics [2]. The decline in mental health among women during pregnancy can be attributed to several factors, such as the unknown effects of COVID-19 on the health of both the mother and fetus, changes and restrictions in prenatal checkup routines and service facilities, and isolation from social support networks due to social distancing measures [3].

Recent research suggests that increased stress during pregnancy and prenatal depression, particularly during a pandemic, can disrupt the maternal-fetal bond [4]. This heightened stress can trigger an overactive response in the fetus, leading to an excessive release of stress hormones in the mother. This, in turn, activates the immune system, potentially causing issues with inflammation and immune regulation [5]. Consequently, this can result in adverse birth outcomes, such as preterm birth or the delivery of babies that are small or of low birthweight for their gestational age [3].

During the pandemic, pregnant women reported significantly elevated stress levels compared to the period before. Their depression was intensified by the fear of infection and a lack of adequate support during childbirth [6]. Prior research has identified marital satisfaction as a significant determinant of prenatal depression [7]. Lower marital satisfaction has been linked to heightened prenatal depression and a reduction in healthcare practices during pregnancy [8]. Prenatal depression is also affected by gestational age, with physical and mental stress escalating in the third trimester. This demonstrates the need for meticulous management of prenatal depression, taking into account the gestational week.

Improving behaviors related to pregnancy healthcare can serve as an effective strategy for reducing prenatal depression. The frequency of breakfast consumption, sleep duration, and drinking habits all have an impact on prenatal depression; thus, a diet rich in vitamins and increased physical activity are recommended during pregnancy [9]. Even amidst a pandemic, participating in online fitness classes can increase physical activity levels, thereby bolstering pregnant women’s resilience against prenatal depression. Moreover, factors associated with physical activity and sleep during pregnancy play a significant role in managing pandemic-related stress, underscoring the importance of reinforcing healthcare practices among pregnant women [10].

Prenatal education can improve the healthcare practices of pregnant women, instilling a sense of preparedness for pregnancy and parenthood. This not only boosts their confidence in childbirth but also mitigates prenatal depression and wards off postpartum depression [11-13]. Prenatal education must evolve to meet the times and the specific needs of pregnant women. However, traditional approaches often overlook the individual circumstances of pregnant women and tend to generalize their experiences [14].

COVID-19 has been linked to significant changes in the mental health, quality of life, attitudes, and lifestyle of pregnant women. There has been a notable increase in stress and depression during this period. Social distancing measures have curtailed their physical activities during leisure time, leading to an increase in time spent at home. Furthermore, there has been a heightened interest in the complications, epidemiology, and treatment of infectious diseases such as COVID-19 [15]. Consequently, this study aims to assess the current state of prenatal education and the impact of pandemic-related pregnancy stress and healthcare practices on prenatal depression. The goal is to provide foundational data and evidence to develop intervention strategies for prenatal education that can enhance mental health and healthcare practices among pregnant women.

The specific aims of this study were as follows:

1) To examine the general and obstetric characteristics of pregnant women and their prenatal education during the COVID-19 pandemic

2) To assess the levels of pandemic-related pregnancy stress, healthcare practices, and prenatal depression during the COVID-19 pandemic

3) To analyze the differences in these factors among pregnant women based on their general, obstetric, and prenatal education characteristics

4) To investigate the correlation between these characteristics, pandemic-related stress, healthcare practices, and prenatal depression

5) To determine the factors associated with prenatal depression among pregnant women during the COVID-19 pandemic

The present study found that 49.4% of pregnant women experienced prenatal depression, as determined by a score of 10 or higher on the K-EPDS. This rate aligns with a previous study [26] conducted during the COVID-19 pandemic, which reported a high prevalence of 56.3% using the same tool and criteria. This high prevalence sharply contrasts with a 21.1% rate found in a pre-pandemic study [27] in Korea, suggesting a significant increase in prenatal depression during the pandemic. The current study identified various risk factors for prenatal depression, each with a distinct impact. These factors include family type, marital satisfaction, prenatal checkups, planned pregnancy, alcohol consumption during pregnancy, desired sex of the fetus, and preferred childbirth method. These findings align with previous research [28,29] on Korean pregnant women. Additionally, this study incorporated COVID-19-related variables such as job loss, changes in income, self-quarantine experience, and alterations in prenatal checkups, all of which were found to influence prenatal depression. Prior research [30] has underscored that prolonged self-quarantine and disrupted prenatal care due to the pandemic can exacerbate prenatal depression. The severity of depression significantly increased in both pregnant and nonpregnant women when self-quarantine exceeded 50 days. This highlights the need for policy discussions about suitable self-quarantine durations for pregnant women and the importance of monitoring their mental health during repeated outbreaks. Consequently, follow-up studies on prenatal depression based on the duration of self-quarantine are crucial. Moreover, 25.6% of participants experienced changes in their prenatal checkups due to the COVID-19 pandemic, and these women reported higher levels of prenatal depression than those who did not experience changes. However, another study [31] found that 37.1% of pregnant women were unable to receive regular checkups due to the pandemic, a rate higher than that observed in this study. Unplanned changes or cancellations in prenatal checkups can leave pregnant women feeling unprepared for childbirth, which can negatively impact their mental health and potentially lead to anxiety, stress, and both prenatal and postnatal depression [32]. Therefore, it is crucial to emphasize the importance of consistent prenatal checkups during infectious disease outbreaks to help pregnant women maintain their mental health.

This study also discovered that pregnant women reported increased levels of prenatal depression during the COVID-19 period when they encountered heightened pandemic-related pregnancy stress, diminished marital satisfaction, insufficient pregnancy healthcare practices, were part of a weekend couple, and were at a more advanced gestational age. These variables accounted for 38.2% of the variation in prenatal depression. Drawing on these findings, this study examined the influence of each factor on prenatal depression, proposed policy implications to tackle these issues, and suggested practical solutions for pregnant women.

Pandemic-related stress during pregnancy was identified as the most significant factor contributing to an increase in prenatal depression, a finding that aligns with previous research [6,33]. This specific type of stress, distinct from typical pregnancy stress, emerged as a major predictor of prenatal depression during the pandemic in this study. Notably, the incidence of prenatal depression was found to be twice as high during the pandemic as compared to pre-pandemic levels, suggesting that the pandemic itself has intensified depression symptoms. Moreover, both objective stressors, such as changes in prenatal checkups, financial difficulties, and unemployment, and subjective stressors, such as fear of COVID-19 infection and limited support during childbirth, have contributed to the heightened depression among pregnant women. In particular, higher levels of subjective stress were closely associated with more severe depression symptoms [6]. Additionally, variations in pandemic-related pregnancy stress were observed in relation to changes in childbirth plans due to the pandemic and pregnancies resulting from infertility treatments. This observation aligns with previous studies that employed similar methodologies [22,34]. Pregnant women infected with COVID-19 faced limited childbirth options, which escalated their fear and stress, potentially leading to PTSD [35]. Therefore, it is crucial to ensure that pregnant women have the right to make choices during childbirth in order to reduce stress during such crises. Women who became pregnant through infertility treatments experienced intense stress from the onset of their pregnancy. Concerns about treatment interruptions and delays during the pandemic [36], as well as the potential for decreased fertility due to infection [37], further exacerbated their depression and stress [36]. In response, policy discussions are needed to ensure the continuity of infertility treatments through medical insurance [36] and to incorporate prenatal care into emergency medical systems during pandemics. Previous research has shown that stress associated with childbirth and postpartum care significantly impacts prenatal depression during a pandemic [33]. Therefore, it is imperative to expand support and resources in prenatal care systems and to enhance pregnant women’s capabilities through prenatal education [33]. In addition, mindfulness interventions, particularly those delivered via mobile apps, have proven effective in reducing stress and alleviating prenatal depression during prolonged periods of infectious disease outbreaks. These interventions also provide high accessibility to mental health information and are well-accepted by pregnant women [38]. Therefore, developing digital health stress management programs that are readily available to pregnant women at any time and place, would be helpful in preparation for recurring infectious diseases.

In the current study, the second most influential factor on prenatal depression during the pandemic was identified as pregnancy healthcare practice behavior, aligning with previous research [10,39]. The extent of these behaviors appears to be influenced by factors such as marital status, family structure, marital satisfaction, self-quarantine experience during pregnancy, and income changes due to the COVID-19 pandemic. These factors are also linked to the social support provided by family members, suggesting that their emotional and material assistance significantly impacts how pregnant women manage their healthcare practices during the pandemic. Typically, pregnant women receive more social support from family and relatives than from friends. Adequate family support has been shown to positively influence health-promoting behaviors [40,41], a finding supported by prior research. This study also discovered that pandemic-related income changes affected pregnancy healthcare practice behaviors. This aligns with another study [40] that found insufficient income negatively impacts women’s health-promoting behaviors. Moreover, a household trend survey in Korea [42] confirmed that the pandemic has led to a decrease in income and an increase in unemployment, which in turn influences changes in household income. Therefore, identifying the material, emotional, and economic support available to pregnant women from family and friends during a pandemic situation and establishing measures to ensure that pregnant women can avoid deficiencies during self-quarantine and maintain their healthcare practices, can be helpful preventive measures against prenatal depression. In this context, promoting healthcare practices among pregnant women during the pandemic is of particular importance. For instance, providing virtual reality-based prenatal group exercise programs tailored to their altered lifestyles can positively impact their bonding with other pregnant women [43].

Prenatal depression was significantly influenced by marital satisfaction, which aligns with previous research [7]. Lower marital satisfaction, which often results in less support from husbands, has been reported as associated with an increase in prenatal depression [7]. This study also found that being a weekend couple, as opposed to living in a large or nuclear family, seemed to result in less support from husbands, which in turn influenced prenatal depression. However, a pre-COVID-19 study [7] found that prenatal depression was twice as prevalent in large families living with parents compared to nuclear families. This suggests the need for further research on family size and weekend couples, especially during pandemic situations. Given that an increase in domestic conflicts and violence were attributed to factors such as unemployment, school closures, and social isolation during the pandemic [44], such factors may likely influence pregnant women's marital satisfaction and should be considered for future research.

Finally, this study identified a correlation between advanced gestational age and prenatal depression, a finding that aligns with prior research [16]. All participants in this study were in their third trimester and exhibited an increase in prenatal depression as their gestational age progressed. Given that the third trimester is a crucial phase for the onset of prenatal depression, largely due to heightened physical and psychological stress [16], greater attention is required as pregnancy progresses, to facilitate early identification and efficient treatment of prenatal depression.

The current study revealed a relatively high level of pandemic-related pregnancy stress, and subscores of 2.03 for stress related to preparedness and 1.47 for perinatal infection. Using the same measurement, higher average scores were reported in prior studies: a US study [22] reported an average score of 3.36 for both subcategories, while an Italian study [45] reported scores of 2.75 and 2.59 for preparedness and perinatal infection stress, respectively. Interestingly, participants in our study experienced less pandemic-related pregnancy stress. This discrepancy may be due to the timing of the study. The US study [22] was conducted during a period of rapidly increasing COVID-19-related deaths [46], and the Italian study [45] took place during a second wave of the pandemic. In contrast, our study in Korea was carried out during a phase of relaxed social distancing measures [17] and COVID-19 transitioning to an endemic phase. This context may account for the lower stress levels observed among our Korean participants compared to those in the previous studies. This also suggests that as time passed, the level of stress experienced during the pandemic gradually decreased, indicating that people have been adapting to the new normal [47]. However, it is important to note that the various traumas experienced during the pandemic could potentially lead to depression or post-pandemic stress disorder even after the pandemic has ended [48]. Therefore, despite the lower levels of pandemic-related pregnancy stress observed among pregnant women in Korea, it is premature to be complacent, monitoring the trends of pregnancy stress as the pandemic concludes and in the subsequent periods would be beneficial.

The high level of pregnancy healthcare practice behaviors in this study (67.07 points) is comparable to the level reported in a pre-COVID-19 study in Korea [25], which recorded an average score of 63.47 to 65.32 using the same evaluation tool. Contrary to expectations that social distancing and isolation would decrease pregnancy healthcare practice behaviors, no such reduction was observed. Interestingly, pregnant women who did not experience social distancing exhibited higher healthcare practice behaviors than those who did. Moreover, women who received prenatal education during the COVID-19 pandemic demonstrated superior healthcare practices compared to those who did not. However, considering that only 33.9% of participants experienced social distancing and 53.3% received prenatal education during the pandemic, these factors did not significantly impact the overall level of the behaviors. Pregnant women who receive professional prenatal education, equipped with accurate prenatal knowledge, can enhance their self-care abilities and healthcare practice behaviors. While face-to-face education was previously the standard, recent advancements in digital technology and the proliferation of infectious diseases have led to the introduction of web- or mobile-based prenatal education programs [25,49]. In light of this, the aim of this study was to investigate the evolving needs and current status of prenatal education for pregnant women during the pandemic. Despite social distancing, self-quarantine, and public facility closures, 53.3% of participants had attended at least one prenatal education session. This is similar to the 53.7% reported in a pre-pandemic study [50]. Regardless of the outcome, a significant 87.2% of participants expressed a need for prenatal education, a figure that substantially exceeds the participation rate. The average interest in prenatal education was around 8 out of 10 points, indicating a significant surge in demand during this period. The primary reasons for not receiving prenatal education were “social distancing” and a “lack of information about when and where the education was available,” suggesting that pandemic-related restrictions were the main obstacles to receiving education.

The internet emerged as the primary source of prenatal information for pregnant women during the COVID-19 pandemic, accounting for 84.4% of all information sources, compared to 30.0% before the pandemic [51] and 82.4% just prior to the pandemic [52]. This indicates an increased dependence on the internet for information. During the pandemic’s peak in Korea, there was a significant decrease in the number of patients and visits to hospitals or clinics compared to the period before the outbreak. This led to a potential decrease in health services provided by primary healthcare facilities [53], and pregnant women may not have received sufficient prenatal information from health professionals, leading to a natural increase in their reliance on the internet. However, the reliability of internet information can be questionable [54], and the information available may not always cater to the specific needs of pregnant women [55]. Therefore, it is crucial to devise policy-level strategies to improve the digital health literacy of pregnant women. This will enable them to effectively search for, understand, and assess the reliability of online prenatal information [56]. Given the recurring nature of infectious diseases, it is imperative for clinical experts to focus on developing strategies that can positively influence pregnant women’s reliance on the internet for prenatal information.

This study also found that the level of prenatal depression was associated with the desired prenatal education mode. Pregnant women who favored face-to-face prenatal education exhibited higher instances of prenatal depression. This can be attributed to the fact that these women seek more than just information from their education; they also crave empathy and emotional support, which they find through bonding with other expectant mothers in similar circumstances [55]. However, online prenatal education may not provide the same opportunities for forming these emotional connections, potentially leading to feelings of isolation [57]. Before the pandemic, prenatal education in Korea was primarily conducted in person at public health centers. While online prenatal education can serve as an effective intervention for prenatal depression during a pandemic, it may not fully address the psychological and emotional needs that are met through social interactions. Consequently, further research is needed to develop effective online prenatal education programs that can be utilized during pandemic conditions.

Based on the findings of this study, the factors that significantly impacted prenatal depression included pandemic-related pregnancy stress, marital satisfaction (or lack thereof), pregnancy healthcare practices, family type (specifically, weekend couples), and gestational age. However, as this study focused solely on women in their third trimester, the results may not be directly applicable to those in their first or second trimesters. Additionally, the survey used to assess prenatal education was conducted in a straightforward question-and-answer format, which limited the ability to provide a comprehensive overview of prenatal education practices during the pandemic. The factors associated with prenatal depression also had a relatively low explanatory power of 38.2%. This could be due to the fact that unlike previous research conducted in Korea during the pandemic [16], this study did not specifically analyze pregnant women with a history of depression or those currently experiencing depression during pregnancy. Despite these limitations, the study’s significance lies in its examination of the changing phenomena by analyzing each variable of pandemic-related pregnancy stress and pregnancy healthcare practices in relation to the characteristics of pregnant women and their prenatal education. The study also provides foundational data for the development of various prenatal education programs aimed at promoting mental health in pregnant women in preparation for future infectious diseases. It further underscores the need for strategies to reduce pregnancy stress and improve pregnancy healthcare behaviors.

In conclusion, prenatal depression among pregnant women during pandemics like COVID-19 is a serious issue that necessitates immediate evaluation and treatment. Because prenatal depression often intensifies in the later stages of pregnancy, interventions that are both timely and tailored to the pregnancy stage are essential. It is critical to acknowledge stress and healthcare practice behaviors as significant influences on prenatal depression during the COVID-19 pandemic. Therefore, monitoring and managing these factors among pregnant women is crucial, particularly in the face of recurring infectious diseases. Consequently, national and healthcare policies, as well as active interventions, are required to address these issues.