The COVID-19 pandemic and perinatal mental health

Mobile interventions targeting common mental disorders among pregnant and postpartum women: An equity-focused systematic review

INTRODUCTION

Pregnant and postpartum women face major psychological stressors that put them at higher risk of developing common mental disorders, such as depression and anxiety. Yet, their limited access to and uptake of traditional mental health care is inequitable, especially during the COVID-19 pandemic. Mobile interventions emerged as a potential solution to this discontinued healthcare access, but more knowledge is needed about their effectiveness and impact on health equity. This equity-focused systematic review examined the effectiveness and equity impact of mobile interventions targeting common mental disorders among pregnant and postpartum women.

METHODS AND RESULTS

We systematically searched MEDLINE, EMBASE, PsychINFO and 3 other databases, from date of database inception and until January 2021, for experimental studies on mobile interventions targeting pregnant and postpartum women. We used pooled and narrative synthesis methods to analyze effectiveness and equity data, critically appraised the methodological rigour of included studies using Cochrane tools, and assessed the certainty of evidence using the GRADE approach. Our search identified 6148 records, of which 18 randomized and non-randomized controlled trials were included. Mobile interventions had a clinically important impact on reducing the occurrence of depression (OR = 0.51 [95% CI 0.41 to 0.64]; absolute risk reduction RD: 7.14% [95% CI 4.92 to 9.36]; p<0.001) and preventing its severity perinatally (MD = -3.07; 95% CI -4.68 to -1.46; p<0.001). Mobile cognitive behavioural therapy (CBT) was effective in managing postpartum depression (MD = -6.87; 95% CI -7.92 to -5.82; p<0.001), whereas other support-based interventions had no added benefit. Results on anxiety outcomes and utilization of care were limited. Our equity-focused analyses showed that ethnicity, age, education, and being primiparous were characteristics of influence to the effectiveness of mobile interventions.

CONCLUSION

As the COVID-19 pandemic has increased the need for virtual mental health care, mobile interventions show promise in preventing and managing common mental disorders among pregnant and postpartum women. Such interventions carry the potential to address health inequity but more rigorous research that examines patients' intersecting social identities is needed.

The risk and protective factors of heightened prenatal anxiety and depression during the COVID-19 lockdown

While pregnant women are already at-risk for developing symptoms of anxiety and depression, this is heightened during the COVID-19 pandemic. We compared anxiety and depression symptoms, as indicators of psychological distress, before and during COVID-19, and investigated the role of partner, social network and healthcare support on COVID-19-related worries and consequently on psychological distress. A national survey, conducted during the first lockdown in The Netherlands, assessed COVID-19 experiences and psychological distress (N = 1421), whereas a comparison sample (N = 1439) was screened for psychological distress in 2017-2018. During COVID-19, the percentage of mothers scoring above the questionnaires' clinical cut-offs doubled for depression (6% and 12%) and anxiety (24% and 52%). Women reported increased partner support during COVID-19, compared to pre-pandemic, but decreased social and healthcare support. Higher support resulted in lower COVID-19-related worries, which in turn contributed to less psychological distress. Results suggest that a global pandemic exerts a heavy toll on pregnant women's mental health. Psychological distress was substantially higher during the pandemic than the pre-pandemic years. We identified a protective role of partner, social, and healthcare support, with important implications for the current and future crisis management. Whether increased psychological distress is transient or persistent, and whether and how it affects the future generation remains to be determined.

Trajectories of perinatal depressive symptoms in the context of the COVID-19 pandemic

This study sought to advance understanding of the potential long‐term consequences of the COVID‐19 pandemic for child development by characterizing trajectories of maternal perinatal depression, a common and significant risk factor for adverse child outcomes. Data came from 393 women (86% White, 8% Latina; mean age = 33.51 years) recruited during pregnancy (n = 247; mean gestational age = 22.94 weeks) or during the first year postpartum (n = 146; mean child age = 4.50 months; 55% female). Rates of depression appear elevated, relative to published reports and to a pre‐pandemic comparison group (N = 155). This study also provides evidence for subgroups of individuals who differ in their depressive symptom trajectories over the perinatal period. Subgroup membership was related to differences in maternal social support, but not to child birth outcomes.

Anxiety and Worries among Pregnant Women during the COVID-19 Pandemic: A Multilevel Analysis

Background. Several studies have identified pregnant women as a vulnerable group during the COVID-19 pandemic. The perinatal period has been identified as a stage of great risk for the mental health of pregnant women, due to a large increase in mental pathologies during this period. In this context, the objective of the present study was to assess the associations between socioeconomic and demographic factors, health concerns and health information management, and anxiety level during the COVID-19 pandemic in pregnant Spanish women. Method. The sample of this cross-sectional study was comprised of 353 pregnant women, aged 18 or older and residing in Spain. Data collection was carried out from 1 June to 30 September 2020. Participants were recruited from Quirónsalud University Hospital of Madrid. Multilevel regression models were built to value the associations between demographic factors, health concerns and health information management, and anxiety level during the COVID-19 pandemic among pregnant women. Results. Reduced working hours and income due to the COVID-19 pandemic were related to increased anxiety levels, as was the level of concern about COVID-19 symptoms, potential complications, contagion and consequences for the baby. Worries caused by restrictive measures adopted against COVID-19 and resulting isolation, delivery, postpartum and breastfeeding were also associated with increased anxiety levels. Being a separated or divorced woman and being informed to a greater extent by a midwife were related to lower anxiety levels. An increase in the degree of information obtained about COVID-19 symptoms, complications, contagion and consequences for the baby, restrictive measures and isolation adopted against COVID-19, delivery, postpartum and breastfeeding, were also related to decreased anxiety levels. Conclusions. The most vulnerable future mothers in terms of anxiety levels are those with reduced working hours and income due to the COVID-19 pandemic, those with a higher level of concern and who had access to a lesser degree of information about COVID-19 (symptoms and complications, contagion and consequences on the baby, restrictive measures and isolation, delivery, postpartum and breastfeeding), as well as pregnant women who have obtained information about COVID-19 during pregnancy from TV.

A Review of the Involvement of Partners and Family Members in Psychosocial Interventions for Supporting Women at Risk of or Experiencing Perinatal Depression and Anxiety

A maternal experience of perinatal mental health conditions can have serious short- and long-term consequences for child development and family relationships. Women with perinatal depression and/or anxiety are primarily supported by their partner/spouse and family. The aim of this review was to synthesise data from studies that have examined the inclusion of partners or family members in psychosocial interventions for women at risk of or experiencing perinatal depression and/or anxiety. A systematic search of five databases was conducted to identify literature published between 2010 and 2020. Nine empirical studies met the eligibility criteria and were independently assessed by two authors using the National Heart, Lung and Blood Institute Quality Assessment Tools and data were extracted and narratively synthesised guided by TIDieR (Template for Intervention Description and Replication) checklist. Eligible studies detailed diverse interventions facilitated by a variety of programme facilitators, with no central model of intervention or study outcome measures evident across the studies. All studies except one reported a significant change in maternal depression and anxiety scores. The interventions had limited evaluation of the woman’s, partner’s or family member’s experiences of involvement in the intervention. Further research is required to firmly establish the effectiveness of co-designed interventions to support the sustainable integration of such interventions into routine perinatal mental health services.

Protocol for the Pregnancy During the COVID-19 Pandemic (PdP) Study: A Longitudinal Cohort Study of Mental Health Among Pregnant Canadians During the COVID-19 Pandemic and Developmental Outcomes in Their Children

BACKGROUND

The COVID-19 pandemic and countermeasures implemented by governments around the world have led to dramatically increased symptoms of depression and anxiety. Pregnant individuals may be particularly vulnerable to the negative psychological effects of COVID-19 public health measures because they represent a demographic that is most affected by disasters and because pregnancy itself entails significant life changes that require major psychosocial and emotional adjustments.

OBJECTIVE

The PdP study was designed to investigate the associations among exposure to objective hardship caused by the pandemic, perceived stress and psychological distress in pregnant individuals, and developmental outcomes in their offspring.

METHODS

The PdP study comprises a prospective longitudinal cohort of individuals who were pregnant at enrollment, with repeated follow-ups during pregnancy and the postpartum period. Participants were eligible if they were pregnant, ≥17 years old, at ≤35 weeks of gestation at study enrollment, living in Canada, and able to read and write in English or French. At enrollment, participants completed an initial survey that assessed demographic and socioeconomic characteristics, previous pregnancies and births, prepregnancy health, health conditions during pregnancy, medications, psychological distress, social support, and hardships experienced because of the COVID-19 pandemic (eg, lost employment or a loved one dying). For the first three months following the initial survey, participants received a monthly email link to complete a follow-up survey that asked about their experiences since the previous survey. After three months, follow-up surveys were sent every other month to reduce participant burden. For each of these surveys, participants were first asked if they were still pregnant and then routed either to the next prenatal survey or to the delivery survey. In the postpartum period, surveys were sent at 3, 6, and 12 months of infant age to assess maternal stress, psychological distress, and infant development.

RESULTS

Participant recruitment via social media (Facebook and Instagram) began on April 5, 2020, and is ongoing. As of April 2021, more than 11,000 individuals have started the initial survey. Follow-up data collection is ongoing.

CONCLUSIONS

This longitudinal investigation seeks to elucidate the associations among hardships, maternal psychological distress, child development during the COVID-19 pandemic, and risk and resilience factors that amplify or ameliorate these associations. The findings of this study are intended to generate knowledge about the psychological consequences of pandemics on pregnant individuals and point toward prevention and intervention targets.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25407.

Psychosocial experiences of postnatal women during the COVID-19 pandemic. A UK-wide study of prevalence rates and risk factors for clinically relevant depression and anxiety

BACKGROUND

When the vulnerabilities of the postnatal period are combined with the impact of the COVID-19 pandemic, psychosocial outcomes are likely to be affected. Specifically, we aim to: a) explore the psychosocial experiences of women in the early postnatal period; b) describe prevalence rates of clinically relevant maternal anxiety and depression; and c) explore whether psychosocial change occurring as a result of COVID-19 is predictive of clinically relevant maternal anxiety and depression.

METHODS

A sample of UK mothers (N = 614) with infants aged between birth and twelve weeks were recruited via convenience sampling. A cross-sectional survey design was utilised which comprised demographics, COVID-19 specific questions, and a battery of validated psychosocial measures, including the EPDS and STAI-S which were used to collect prevalence rates of clinically relevant depression and anxiety respectively. Data collection coincided with the UK government's initial mandated "lockdown" restrictions and the introduction of social distancing measures in 2020.

FINDINGS

Descriptive findings from the overall sample indicate that a high percentage of mothers self-reported psychological and social changes as a result of the introduction of social distancing measures. For women who reported the presence of psychosocial change, these changes were perceived negatively. Whilst seventy women (11.4%) reported a current clinical diagnosis of depression, two hundred and sixty-four women (43%) reported a score of ≥13 on the EPDS, indicating clinically relevant depression. Whilst one hundred and thirteen women (18.4%) reported a current clinical diagnosis of anxiety, three hundred and seventy-three women (61%) reported a score of ≥40 on STAI-S, indicating clinically relevant anxiety. After accounting for current clinical diagnoses of depression or anxiety, and demographic factors known to influence mental health, only perceived psychological change occurring as a result of the introduction of social distancing measures predicted unique variance in the risk of clinically relevant maternal depression (30%) and anxiety (33%).

INTERPRETATION

To our knowledge, this is the first national study to examine the psychosocial experiences of postnatal women during the COVID-19 pandemic in the UK. Prevalence rates of clinically relevant maternal depression and anxiety were extremely high when compared to both self-reported current diagnoses of depression and anxiety, and pre-pandemic prevalence studies. Perceived psychological changes occurring as a result of the introduction of social distancing measures predicted unique variance in the risk for clinically relevant maternal depression and anxiety. This study provides vital information for clinicians, funders, policy makers, and researchers to inform the immediate next steps in perinatal care, policy, and research during COVID-19 and future health crises.

Breastfeeding during COVID-19: A Narrative Review of the Psychological Impact on Mothers

The COVID-19 pandemic has altered the normal course of life, with measures to reduce the virus spread impacting motherhood expectations and, in particular, breastfeeding practices. This study aimed to review evidence regarding the impact of COVID-19 on breastfeeding plans and how these relate to women's psychological outcomes. Searches were conducted on PubMed and Web of Science for studies in English, Spanish, and Portuguese between January 2020 and January 2021. All study designs and pre-prints were considered. Twelve studies were included. Reports suggest that COVID-19 impacts differently on breastfeeding plans, which in turn leads to distinctive mental health outcomes. Positive breastfeeding experiences have been observed when mothers perceive that they have more time for motherhood, which may be associated with better mental health outcomes. Negative breastfeeding experiences have been observed when mothers are separated from their newborns, when mothers struggle with breastfeeding, or when mothers perceive decreased family and professional support, which seems to be associated with worse mental health outcomes. These preliminary results highlight the need for further research into the association between COVID-19, breastfeeding expectations, and maternal mental health. Filling this gap will foster the development of guidelines and interventions to better support mothers experiencing the obstacles of COVID-19 pandemic.

Perceived social support and prenatal wellbeing; The mediating effects of loneliness and repetitive negative thinking on anxiety and depression during the COVID-19 pandemic

Problem

Prenatal depression and anxiety are linked to poor maternal and infant outcomes. We need to understand predictors of poor mental health to identify at-risk women, and targets for support.

Background

Previous research has demonstrated a relationship between low levels of perceived social support, and depression and anxiety in pregnant women. However, there is a lack of research into the factors that may mediate this relationship.

Aim

As social distancing measures (e.g., lockdown) are likely to negatively affect women’s perceived support in the prenatal period, we investigated the relationship between perceived social support and both anxiety and depression in UK-based pregnant women during the COVID-19 pandemic. Further, we examined two potential mediators that may contribute to psychological symptoms: repetitive negative thinking and loneliness.

Methods

We administered a battery of online measures to a sample of pregnant women (N = 205) between May-June 2020, during the first peak of the pandemic in the UK, when perceived social support was likely to be low.

Results

Consistent with predictions, perceived social support was significantly negatively related to depression, anxiety, loneliness and repetitive negative thinking. Furthermore, repetitive negative thinking and loneliness mediated the relationship between perceived social support and both depression and anxiety. Moreover, perceived social support and loneliness were associated with specific types of online behaviours.

Conclusions

Taken together, the findings shed light on the processes through which social support may exert its effects on depression and anxiety and highlight potential therapeutic targets for interventions which aim to prevent and treat mood disorders in perinatal cohorts.

Challenges and opportunities of the COVID-19 pandemic for perinatal mental health care: a mixed-methods study of mental health care staff

The aim of this study was to explore staff perceptions of the impact of the COVID-19 pandemic on mental health service delivery and outcomes for women who were pregnant or in the first year after birth ('perinatal' women). Secondary analysis was undertaken of an online mixed-methods survey open to all mental health care staff in the UK involving 363 staff working with women in the perinatal period. Staff perceived the mental health of perinatal women to be particularly vulnerable to the impact of stressors associated with the pandemic such as social isolation (rated by 79.3% as relevant or extremely relevant; 288/363) and domestic violence and abuse (53.3%; 192/360). As a result of changes to mental health and other health and social care services, staff reported feeling less able to assess women, particularly their relationship with their baby (43.3%; 90/208), and to mobilise safeguarding procedures (29.4%; 62/211). While 42% of staff reported that some women engaged poorly with virtual appointments, they also found flexible remote consulting to be beneficial for some women and helped time management due to reductions in travel time. Delivery of perinatal care needs to be tailored to women's needs; virtual appointments are perceived not to be appropriate for assessments but may be helpful for some women in subsequent interactions. Safeguarding and other risk assessment procedures must remain robust in spite of modifications made to service delivery during pandemics.

Risk factors for depression, anxiety, and PTSD symptoms in perinatal women during the COVID-19 Pandemic

BACKGROUND

Pregnant women and women who recently gave birth are vulnerable to COVID-19-related psychosocial stresses.

METHODS

We assessed COVID-19-related health worries and grief, and current mental health symptoms (depression, generalized anxiety, and PTSD) in 1,123 U.S. women during the COVID-19 pandemic (May 21 to August 17, 2020) through a cross-sectional study design.

RESULTS

Among our respondents, 36.4% reported clinically significant levels of depression, 22.7% for generalized anxiety, and 10.3% for PTSD. Women with pre-existing mental health diagnoses based on their self-reported history were 1.6-to-3.7 more likely to score at clinically significant levels of depression, generalized anxiety, and PTSD. Approximately 18% reported high levels of COVID-19-related health worries and were 2.6-to-4.2 times more likely to score above the clinical threshold for mental health symptoms. Approximately 9% reported high levels of grief and were 4.8-to-5.5 times more likely to score above the clinical threshold for mental health symptoms.

CONCLUSIONS

Perinatal women with pre-existing mental health diagnoses show elevated symptoms during the COVID-19 pandemic. Although causation cannot be inferred, COVID-19-related health worries and grief experiences may increase the likelihood of mental health symptoms among those without pre-existing mental health concerns. Providers should develop strategies for addressing health-related worry and grief within their practice.

Maternal mental health and well-being during the COVID-19 pandemic in Beijing, China

BACKGROUND

The aim of this study is to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on breastfeeding women and to identify predictors of maternal mental health and coping.

METHODS

Mothers aged ≥ 18 years with a breast-fed infant ≤ 18 months of age during the COVID-19 pandemic in Beijing, China, completed a questionnaire. Descriptive analysis of lockdown consequences was performed and predictors of these outcomes were examined using stepwise linear regression.

RESULTS

Of 2233 participants, 29.9%, 20.0% and 34.7% felt down, lonely, and worried, respectively, during the lockdown; however, 85.3% felt able to cope. Poorer maternal mental health was predicted by maternal (younger age, higher education) and infant (older age, lower gestation) characteristics, and social circumstances (husband unemployed or working from home, receiving advice from family, having enough space for the baby, living close to a park or green space). Conversely, better maternal mental health was predicted by higher income, employment requiring higher qualifications, more personal space at home, shopping or walking > once/week and lack of impact of COVID-19 on job or income. Mothers with higher education, more bedrooms, fair division of household chores and attending an online mother and baby group > once/week reported better coping.

CONCLUSION

The findings highlight maternal characteristics and circumstances that predict poorer mental health and reduced coping which could be used to target interventions in any future public health emergencies requiring social restrictions.

Vulnerability and resilience to pandemic-related stress among U.S. women pregnant at the start of the COVID-19 pandemic

RATIONALE

Women pregnant during the COVID-19 pandemic are experiencing moderate to high levels of emotional distress, which has previously been shown to be attributable to two types of pandemic-related pregnancy stress: stress associated with feeling unprepared for birth due to the pandemic (Preparedness Stress) and stress related to fears of perinatal COVID-19 infection (Perinatal Infection Stress).

OBJECTIVE

Given the well-documented harms associated with elevated prenatal stress and the critical importance of developing appropriately targeted interventions, we investigated factors predictive of pandemic-related pregnancy stress.

METHOD

Between April 25 and May 15, 2020, 4,451 pregnant women in the U.S. were recruited via social media to complete an online questionnaire that included sociodemographic, medical, and COVID-19 situational factors, as well as the Pandemic-Related Pregnancy Stress Scale (PREPS). Binary logistic regression was used to calculate odds ratios for high stress.

RESULTS

Nearly 30% of participants reported high Preparedness Stress; a similar proportion reported high Perinatal Infection Stress. Abuse history, chronic illness, income loss due to the pandemic, perceived risk of having had COVID-19, alterations to prenatal appointments, high-risk pregnancy, and being a woman of color were associated with greater levels of one or both types of stress. Access to outdoor space, older age, and engagement in healthy behaviors were protective against stress.

CONCLUSIONS

Practices that may alleviate pandemic-related stress such as minimizing disruptions to prenatal care, ensuring access to outdoor space, and motivating engagement in health behaviors are of vital importance. Particular attention is needed for more vulnerable populations including women of color, women with a history of abuse, and those with high-risk pregnancy. Research focused on the short and longer-term impact of pandemic-related pregnancy stress on maternal mental and physical health, perinatal outcomes, and child development is critical to identify these effects and marshal appropriate resources to reduce them.

The German version of the pandemic-related pregnancy stress scale: A validation study

OBJECTIVE

The consequences of the COVID-19 pandemic may lead to exceptional stress in pregnant women. In order to evaluate stress levels of pregnant woman in this difficult time, the Pandemic-Related Pregnancy Scale (PREPS) was introduced in the US. The present study introduces and validates the German version of the PREPS.

STUDY DESIGN

In total, 1364 German-speaking pregnant women from Germany and Switzerland took part in this online cohort study and completed the PREPS as well as gave information on sociodemographic, obstetric and other psychological factors.

RESULTS

A confirmatory factor analysis of the PREPS showed very good psychometric values and confirmed the structure of the original questionnaire. The PREPS comprises three dimensions: Infection Stress (5 items), Preparedness Stress (7 items) and Positive Appraisal (3 items). Furthermore, correlations between the PREPS and other psychological factors such as Pregnancy Specific Stress and Fear of Childbirth highlight convergent validity. The sensitivity of the questionnaire was demonstrated by its associations with several obstetric and COVID-19 related factors.

CONCLUSION

The German PREPS showed good psychometric properties and is a useful instrument for future studies which aim to investigate the impact of pandemic-related stress on birth outcomes and postpartum factors.

The COVID-19 Pandemic Can Impact Perinatal Mental Health and the Health of the Offspring

The COVID-19 ongoing pandemic constitutes a major challenge for countries throughout the world due to the rapid spread of SARS-CoV-2 and devastating consequences in health. No one is free from COVID-19 impact. In this regard, pregnant women are not the exception. The COVID-19 outbreak represents a massive source of stressful agents for women and their babies during the perinatal period. The COVID-19 pandemic has been suggested to potentially have short- and long-term detrimental effects on pregnant women and the baby. These adverse consequences range from mental to medical diseases. During the last centuries, several dreadful and fatal incidents have put pregnant women and their babies at higher risk of mortality and health deterioration. For example, it has been informed that women exposed to the 1918 flu pandemic (commonly known as the Spanish flu) while pregnant showed higher rates of premature delivery in the short term. Long-term consequences have also been reported and individuals (both males and females) who were exposed to the 1918 flu pandemic while in utero had a higher risk of developing schizophrenia, diabetes, coronary heart disease or cancer throughout their lifespan.