Maternal Stress During COVID-19 Showed Mixed Links to Pregnancy Outcomes in Iranian Cohort

A prospective cohort study of 392 pregnant women in Iran has found that maternal mental distress during the first wave of the COVID-19 pandemic was associated with pregnancy outcomes in unexpected directions, with perceived stress linked to both lower odds of hypertension and higher odds of delivering a small-for-gestational-age infant.

The study, published in BMC Pregnancy and Childbirth, recruited women receiving care at comprehensive health centers affiliated with Golestan University of Medical Sciences. Researchers assessed mental distress using validated instruments: the Perceived Stress Scale (PSS-10), the state subscale of the State-Trait Anxiety Inventory, and the Beck Depression Inventory (BDI-13). Participants also answered two questions about their perceived risk of COVID-19, and their preventive behavior scores were recorded.

Pregnancy outcomes were not self-reported. Instead, the team drew them from the NAB Electronic Health Records system, which allowed the researchers to link each woman’s psychological measures to documented maternal and neonatal outcomes. Logistic regression models were then applied to examine the associations between measures of mental distress and pregnancy outcomes.

The results revealed a differentiated pattern rather than a uniform effect of distress. Perceived stress was significantly associated with lower odds of hypertension, with an odds ratio of 0.89 (p = 0.03), and with higher odds of small-for-gestational-age birth, with an odds ratio of 1.08 (p = 0.02). Perceived risk of COVID-19 was associated with lower odds of preeclampsia, with an odds ratio of 0.57 (p = 0.02).

Preventive behavior showed its own distinct association. Higher preventive behavior scores were linked to greater odds of small-for-gestational-age birth, with an odds ratio of 1.52 (p = 0.01). This was the strongest association reported in the study, suggesting that the behaviors women adopted to protect themselves from infection may have been more closely tied to fetal growth outcomes than the psychological measures themselves.

Notably, neither depression nor trait anxiety showed a statistically significant association with any of the maternal or neonatal outcomes examined. This absence of association contrasts with the broader suggestion in the literature that mental distress is a significant risk factor for poor maternal and neonatal outcomes, and it underscores that different dimensions of distress may behave differently when measured during a pandemic.

The authors concluded that some levels of perceived stress were associated with lower odds of hypertension, while both perceived stress and preventive behaviors were associated with higher odds of small-for-gestational-age birth, and that perceived risk of COVID-19 was associated with lower odds of preeclampsia. They emphasized that maternal mental distress and preventive behaviors may be differentially associated with maternal and neonatal outcomes, and that further studies are needed to clarify these relationships.

Several caveats are important when interpreting these findings. The study examined associations, not causal effects, and the odds ratios for stress and small-for-gestational-age birth were close to one, indicating modest effect sizes. The cohort was drawn from a single region of Iran during the first pandemic wave, so the results may not generalize to other populations or later stages of the pandemic. In addition, the article was published as an early-access version carrying a permanent DOI, subject to further edits before the final Version of Record appears. The counterintuitive direction of some associations, particularly the link between perceived risk and lower odds of preeclampsia, remains unexplained and will require replication in independent cohorts before any clinical interpretation is possible.

Subject of Research: Associations between maternal mental distress and pregnancy outcomes during the COVID-19 pandemic in Iran

Article Title: Can maternal mental distress predict pregnancy outcomes during the COVID-19 pandemic?

Article References: Moghasemi, S., Moodi, S., & Mehrbakhsh, Z. (2026). Can maternal mental distress predict pregnancy outcomes during the COVID-19 pandemic?. BMC Pregnancy and Childbirth. https://doi.org/10.1186/s12884-026-10073-9

Image Credits: AI Generated

DOI: 10.1186/s12884-026-10073-9

Keywords: maternal mental distress, COVID-19 pandemic, pregnancy outcomes, perceived stress, preeclampsia, small-for-gestational-age, hypertension, preventive behaviors, prospective cohort, Iran, anxiety, depression