On January 30, 2020, the Director-General of the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern. This infectious disease is still a major global public health threat [1, 2]. The COVID-19 pandemic has brought unprecedented changes to people’s lives both directly and indirectly through lifestyle changes, physical distancing, and socioeconomic restructuring. These changes affect people’s moods and mental health in the long term. Many reports indicate that people have developed mental health problems due to the pandemic [3, 4]. This is particularly applicable to women. For example, reports show that in China, the prevalence of post-traumatic stress symptoms is high among women living in areas strongly impacted by COVID-19 [5]. There is also a significant relationship between being female and experiencing increased stress, anxiety, and overall psychological effects [6, 7]. According to a sophisticated systematic review, being female is associated with lower psychological well-being and higher anxiety and depression scores as indirect effects of the pandemic [8].

Many studies highlight the gender differences in the risk of depression [9]. Women are 2.48 times more likely than men to be diagnosed with depression or anxiety, and there is a clear causal relationship between their mental condition and stressful life events [10].

On April 7, 2020, the Japanese government declared a national state of emergency; subsequently, 13 areas were designated as “Prefectures under Specific Cautions,” where citizens were restricted from going out and migrating to other prefectures. These daily life restrictions were reported to aggravate depression and anxiety among mothers with preschoolers [11].

In recent years, risk factors associated with the COVID-19 pandemic and suicide attempts have been the focus of worldwide attention. Several studies have shown that financial crises due to loss of employment were risk factors associated with suicide and suicide attempts during the COVID-19 pandemic [12, 13]. In addition, suicide rates were found to increase depending on social distance and degree of isolation [14, 15].

WHO recognizes suicide prevention as a public health priority and has been closely monitoring changes in suicide rates following the pandemic.

Japan has one of the highest suicide death rates internationally, with about 20,000 people committing suicide each year [16]. Compared to the previous year, suicide rates among women were reported to increase by 30% in 2020 due to the COVID-19 pandemic [17]. It is speculated that this is because of women’s economic hardships and mental health problems, but the causes of these problems have not been fully investigated [18]. Many women in their 20s and 30s with infants were among those who committed suicide [19].

Even before the pandemic, Japan had been marked by mothers’ maternal anxiety about child-rearing, a concept similar to childcare stress among mothers caring for preschoolers [20]. Japanese mothers’ “anxiety about child-rearing” has been reported to be a complex concept and has the potential to predict not only the mental health of mothers but also the mother-child relationship and child development [21].

Thus, it would be beneficial to develop public health measures to clarify how the mental health of women raising preschoolers is affected by the pandemic and the risk factors.

This study aims to clarify the neurosis experienced by women raising preschoolers in Japan amid the COVID-19 pandemic and identify the factors behind it.

This study was a cross-sectional survey. In December 2020, we screened 6000 women, aged 20–55 years, registered on a web-based internet survey company (Freeasy; iBRIDGE Company, Tokyo, Japan) to determine if they had any children. The iBRIDGE Company is an exclusive research panel agency established in 2006, with approximately 274,317 voluntarily registered participants. This study was conducted during the spread of the COVID-19 pandemic. We anticipated that the presence of a family member who was infected with COVID-19 would potentially affect the results. Therefore, individuals who currently (at the time of the study) or previously had an infected family member were excluded. We shortlisted 2,391 women who answered “yes” to the question, “Do you have preschool children (0–6 years)?” and had no infected family members. Of these, 730 (30.5%) completed the web questionnaire. The registration information also included the age, marital status, children (if any, the number of children and their age), household income, working status, and prefecture of residence. The participants were residents from all 47 prefectures in Japan.

The sample size for this study was calculated using a population of 12 million Japanese women aged 20–39 years. The minimum sample size required for our study was 387 according to an apriori power analysis using the Raosoft sample size calculator, based on a 95% confidence level (CI), 5% margin of error, and an anticipated response rate of 50%. The required sample size was found to be 665 when the confidence level increased to 99% using the same formula. We confirmed that the sample size of our study was sufficient.

All procedures conducted were approved by the Medical Faculty Ethics Committee of Niigata University (IR. 2020-0297). Informed consent was electronically obtained before data were collected from the participants.

This study, conducted in 2020, approximately one year after the outbreak of the COVID-19 pandemic, examined the factors affecting the mental health of women raising preschoolers in Japan. Vaccines for COVID-19 were unavailable in Japan at the time of data collection.

Among the participants of this study, 41.5% were mentally unhealthy, according to the GHQ-12 scores. This figure is similar to that of women in Spain during the lockdown [27]. While it has been reported that 65.6% of healthcare workers in Japan, who are under heavy stress during the pandemic, have a GHQ-12 score of 4 or higher [28], the figures of this study’s participants did not reach the level of healthcare workers. Even so, they may be experiencing severe mental distress.

Results revealed that the mental health problems of the participants were not related to whether they lived in an area where activities were restricted due to the state of emergency. However, they were strongly related to maternal anxiety about child-rearing amid the COVID-19 pandemic. Other than maternal anxiety about child-rearing, factors negatively impacting the participants’ mental health were their children’s temperature, worrying about whether their children washed their hands, hesitation to see a doctor, and caring for children at home.

Studies on the prevalence of COVID-19 mental health in Asia found that age and gender are important predictors of adverse psychological effects [29, 30]. In a study of Southeast Asian countries, a significant prevalence of adverse mental health was found among young women, with higher rates among the more educated [31]. These results support the evidence that women were severely affected by the COVID-19 pandemic due to their increased workload, both at work and home, a higher risk of domestic violence, and a lack of resilience in dealing with the crisis. However, the aspect of the child-rearing burden has received less attention.

In Japan, fear of infection has led to a reluctance to see pediatricians. As a result, the number of outpatients decreased by up to 80% compared to pre-pandemic levels and by 40% on average. However, it is reported that patients tended to visit doctors only after they became critically ill [32]. This suggests that children are cared for at home until they become critically ill [33].

While there are reports that the stressors related to lockdowns and telecommuting amid the pandemic were strongly associated with mental disorders [34], the situation in Japan was such that mental health problems also emerged among mothers living in areas that were not under lockdown. No differences were observed between those who had a job and those who did not, indicating that changes in workstyles were unrelated to changes in mental conditions.

Japanese mothers had been experiencing high levels of anxiety and burden regarding child-rearing even before the pandemic. Moreover, it has been reported that their anxiety intensifies when they accompany sick children to the hospital [35].

In Japan, a high suicide rate among the youth has been a major public health concern. Among six major industrialized countries, suicide is a leading cause of death among the youth only in Japan. In particular, suicide is the leading cause of death among women aged 15–29 [36]. Their psychological difficulties might have been compounded by the pandemic. In 2020, it was reported that suicides among women increased by 20% to 30% because of the COVID-19 pandemic. Difficulties in visiting a doctor due to hospital closures or avoiding visiting a doctor because of the fear of infection would be very stressful for mothers and cause distress. The present study also suggests poor education leads to high GHQ-12 scores. During the SARS pandemic in 2003, it was indicated that people’s ability to gather and understand information played an important role in halting the spread of the disease [37]. During a pandemic, the government must provide information on clinics and hospitals that provide emergency treatment. At the same time, it is necessary to strengthen health literacy, including media use among people, and dispense correct knowledge of infectious diseases and preventive measures.

While previous discussions have suggested that medium- to long-term economic uncertainty associated with COVID-19 would increase people’s mental burden and raise the risk of depression, no clear relationship was observed between income and mental health among the participants of this study. More than half of the participants had annual incomes exceeding 4,730,000 yen (about 32,000 USD), the average household income in Japan. This suggests that they were not impacted significantly by economic hardship.

In light of the above, it is recommended that the government or mental health institutions provide counseling for mothers and children confined to their homes and help them recover from the effects of COVID-19. It is also desirable that they create a program for providing individual consultations or plan individual visits. Thus, the results of this study may be useful in predicting who is likely to suffer from mental health problems during a pandemic in Japan.

This study was conducted to investigate the impact of the COVID-19 pandemic on mothers raising preschoolers in Japan. In this study, the GHQ-12 scores indicated a prevalence of clinically significant levels of psychological distress among 41.5% of the participants, with “Maternal anxiety about child-rearing” as the most effective predictor of psychological distress. Moreover, although 31.5% of the respondents resided in “Prefectures under Specific Cautions,” the regional characteristics were not significant predictors. Mothers with preschoolers often experience mental distress due to a sense of entrapment caused by the pandemic and anxiety about childcare; thus, there is a need for psychological care for women with children confined to their homes.