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Ohashi Y, Shoji M, Hanawa K, Yokomichi H, Ishiguro H. A parent-rating scale of postpartum depression: Maternity-monitoring scale by parents (MMSP). J Psychiatr Res 2024; 171:197-206. [PMID: 38306730 DOI: 10.1016/j.jpsychires.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 09/24/2023] [Accepted: 01/16/2024] [Indexed: 02/04/2024]
Abstract
Postpartum depression (PPD) is an illness that is difficult for the affected women themselves to recognize. Moreover, many mothers believe that mothers should not complain about the mental difficulties of taking care of their children. Therefore, in addition to self-evaluation for PPD, evaluation from others is also necessary. We aimed to develop a novel measure to screen for PPD based on a parent-rating scale that is administered to the parents of postpartum mothers. The 15-item maternity-monitoring scale by parents (MMSP) was designed and applied to the feasibility cohort (n = 61) and the emergency cohort (n = 55). The Edinburgh Postnatal Depression Scale (EPDS) (threshold score of 8/9) was used to evaluate a high risk of PPD. An egogram-based index, the over-adaptation index for depression (OAID), was performed along with the EPDS and MMSP. In the feasibility cohort, MMSP was moderately correlated with EPDS. In the emergency cohort, under the circumstance of the state of emergency declaration over the coronavirus disease 2019 in Japan, application of the MMSP was delayed, resulting in the proportion of parents who overlooked PPD symptoms in their daughters increasing from 33 % to 50 %. Our findings suggest that a novel approach of parent-rated PDD screening of postpartum women is potentially possible, and the MMSP is a potential candidate for screening. Moreover, the OAID is also helpful in identifying women with hidden PPD, along with the EPDS. The performance of the MMSP should be confirmed in the parents of patients with PPD diagnosed by psychiatrists.
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Affiliation(s)
- Yoshiaki Ohashi
- Human Metabolome Technologies, Inc., Tsuruoka-city, Yamagata, Japan
| | - Miho Shoji
- Human Metabolome Technologies, Inc., Tsuruoka-city, Yamagata, Japan
| | - Kaori Hanawa
- Human Metabolome Technologies, Inc., Tsuruoka-city, Yamagata, Japan
| | - Hiroshi Yokomichi
- Department of Epidemiology and Environmental Medicine, Graduate School of Medicine, University of Yamanashi, Chuo-city, Yamanashi, Japan
| | - Hiroki Ishiguro
- Pre- and Post-partum Wellbeing Center, Hospital, University of Yamanashi, Chuo-city, Yamanashi, Japan; Department of Clinical Genetics, Graduate School of Medicine, University of Yamanashi, Chuo-city, Yamanashi, Japan; Department of Neuropsychiatry, Graduate School of Medicine, University of Yamanashi, Chuo-city, Yamanashi, Japan.
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Robbins N, Harvey K, Moller MD. Emotional Freedom Techniques for Postpartum Depression, Perceived Stress, and Anxiety. Nurs Womens Health 2024; 28:41-49. [PMID: 38103574 DOI: 10.1016/j.nwh.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/10/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To examine the effect of an Emotional Freedom Techniques (EFT) group intervention on perceived stress, depression, and anxiety symptoms in women in the postpartum period. DESIGN A one-group pre- and posttest quasi-experimental design. SETTING/LOCAL PROBLEM Postpartum depression (PPD) and anxiety affect nearly one in five women in the first 12 months after childbirth. The COVID-19 pandemic was associated with a significant worsening of symptoms of PPD, stress, and anxiety in this population. Mental health screening is the standard of care in perinatal settings. This practice has led to an increased rate of PPD and anxiety diagnoses and the need for evidence-based nonpharmacologic interventions to support mothers with PPD and anxiety. PARTICIPANTS Eleven mothers seeking care for lactation concerns who screened positive for PPD and anxiety symptoms. INTERVENTION/MEASUREMENTS A total of eight 1-hour group EFT sessions were offered to participants over a period of 4 weeks. During the group sessions, participants were taught how to perform the steps of EFT and apply it in a supportive group format. Measurement tools included the Subjective Unit of Distress Scale, Edinburgh Postnatal Depression Scale, and Generalized Anxiety Disorder-7. The preintervention and postintervention scores of these tools were compared using a paired-samples t test. RESULTS After implementing EFT as a group intervention, we observed a reduction in mental health burden experienced by women in the postpartum period. There was a statistically significant decrease in depression (p = .003), anxiety (p <.001), and perceived stress (p <.001) scores 1 month after the EFT intervention. CONCLUSION These findings suggest that EFT may be a viable adjunctive intervention for managing depression, anxiety, and stress in the postpartum period. Further research with larger and more diverse samples is needed to confirm these findings.
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Cherbuin N, Bansal A, Dahlstrom JE, Carlisle H, Broom M, Nanan R, Sutherland S, Vardoulakis S, Phillips CB, Peek MJ, Christensen BK, Davis D, Nolan CJ. Bushfires and Mothers' Mental Health in Pregnancy and Recent Post-Partum. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 21:7. [PMID: 38276795 PMCID: PMC10815782 DOI: 10.3390/ijerph21010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/21/2023] [Accepted: 12/08/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND The compounding effects of climate change catastrophes such as bushfires and pandemics impose significant burden on individuals, societies, and their economies. The enduring effects of such syndemics on mental health remain poorly understood, particularly for at-risk populations (e.g., pregnant women and newborns). The aim of this study was to investigate the impact of direct and indirect exposure to the 2019/20 Australian Capital Territory and South-Eastern New South Wales bushfires followed by COVID-19 on the mental health and wellbeing of pregnant women and mothers with newborn babies. METHODS All women who were pregnant, had given birth, or were within three months of conceiving during the 2019/2020 bushfires, lived within the catchment area, and provided consent were invited to participate. Those who consented were asked to complete three online surveys. Mental health was assessed with the DASS-21 and the WHO-5. Bushfire, smoke, and COVID-19 exposures were assessed by self-report. Cross-sectional associations between exposures and mental health measures were tested with hierarchical regression models. RESULTS Of the women who participated, and had minimum data (n = 919), most (>75%) reported at least one acute bushfire exposure and 63% reported severe smoke exposure. Compared to Australian norms, participants had higher depression (+12%), anxiety (+35%), and stress (+43%) scores. Women with greater exposure to bushfires/smoke but not COVID-19 had poorer scores on all mental health measures. CONCLUSIONS These findings provide novel evidence that the mental health of pregnant women and mothers of newborn babies is vulnerable to major climate catastrophes such as bushfires.
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Affiliation(s)
- Nicolas Cherbuin
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 2601, Australia
| | - Amita Bansal
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
- John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
| | - Jane E. Dahlstrom
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
- John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
- The Canberra Hospital, Canberra Health Services, Garran, ACT 2605, Australia; (H.C.)
| | - Hazel Carlisle
- The Canberra Hospital, Canberra Health Services, Garran, ACT 2605, Australia; (H.C.)
| | - Margaret Broom
- The Canberra Hospital, Canberra Health Services, Garran, ACT 2605, Australia; (H.C.)
- School of Nursing and Midwifery, University of Canberra, Bruce, ACT 2617, Australia;
| | - Ralph Nanan
- Sydney Medical School and Charles Perkins Centre Nepean, University of Sydney, Penrith, NSW 2750, Australia;
| | - Stewart Sutherland
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
| | - Sotiris Vardoulakis
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 2601, Australia
| | - Christine B. Phillips
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
| | - Michael J. Peek
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
| | - Bruce K. Christensen
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
| | - Deborah Davis
- School of Nursing and Midwifery, University of Canberra, Bruce, ACT 2617, Australia;
- Nursing and Midwifery Office, ACT Government Health Directorate, Phillip, ACT 2606, Australia
| | - Christopher J. Nolan
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia; (A.B.); (C.J.N.)
- John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
- The Canberra Hospital, Canberra Health Services, Garran, ACT 2605, Australia; (H.C.)
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Ohashi Y, Takegata M, Takeda S, Hada A, Usui Y, Kitamura T. Is Your Pregnancy Unwanted or Unhappy? Psychological Correlates of a Cluster of Pregnant Women Who Need Professional Care. Healthcare (Basel) 2023; 11:2196. [PMID: 37570436 PMCID: PMC10418804 DOI: 10.3390/healthcare11152196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND A negative response towards a current pregnancy consists of two elements: unwantedness of and unhappiness about the current pregnancy. Little is clear about whether pregnant women can be categorized in terms of unwantedness and unhappiness as well as what the correlates are of these categories. METHODS An internet survey of 696 women in their first trimester of pregnancy examined the participants' intention of and emotional reaction towards pregnancy, borderline personality traits, adult attachment style, depression, fear of childbirth, obsessive-compulsive symptoms, fetal bonding disorder, avoidance of taking part in child care, and consideration about termination of pregnancy (TOP). About one third of the participants were followed up with in their second trimester. RESULTS Two-step cluster analysis using the participants' intention of and emotional reaction towards pregnancy revealed three groups of pregnant women: those who wanted and were happy about the pregnancy (Cluster 1), those who were unhappy about the pregnancy (Cluster 2), and those who did not intend to be pregnant but were happy about pregnancy (Cluster 3). Cluster 2 women, but not Cluster 3 women, were likely to be single, with borderline personality traits as well as unstable adult attachment styles, accompanied by depression, fear of childbirth, obsessive-compulsive symptoms, and fetal bonding disorder. They were more likely to avoid caring for the baby after childbirth and consider TOP. CONCLUSION Expectant women who were unhappy about their pregnancy were at risk of psychological adjustment and need specific perinatal mental health assessment and care.
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Affiliation(s)
- Yukiko Ohashi
- Faculty of Nursing, Josai International University, Togane 283-8555, Japan;
- Kitamura Institute of Mental Health Tokyo, Tokyo 151-0063, Japan; (M.T.); (A.H.)
| | - Mizuki Takegata
- Kitamura Institute of Mental Health Tokyo, Tokyo 151-0063, Japan; (M.T.); (A.H.)
| | - Satoru Takeda
- Department of Obstetrics & Gynecology, Faculty of Medicine, Juntendo University, Tokyo 113-8421, Japan;
- Aiiku Research Institute for Maternal, Child Health and Welfare, Imperial Gift Foundation Boshi-Aiiku-Kai, Tokyo 106-8580, Japan
| | - Ayako Hada
- Kitamura Institute of Mental Health Tokyo, Tokyo 151-0063, Japan; (M.T.); (A.H.)
- Kitamura KOKORO Clinic Mental Health, Tokyo 151-0063, Japan
- Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
| | - Yuriko Usui
- Department of Midwifery and Women’s Health, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan;
| | - Toshinori Kitamura
- Kitamura Institute of Mental Health Tokyo, Tokyo 151-0063, Japan; (M.T.); (A.H.)
- Kitamura KOKORO Clinic Mental Health, Tokyo 151-0063, Japan
- T. and F. Kitamura Foundation for Studies and Skill Advancement in Mental Health, Tokyo 151-0063, Japan
- Department of Psychiatry, Graduate School of Medicine, Nagoya University, Nagoya 464-8601, Japan
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Ahmed GK, Salman SA, Elbeh K, Amer ZS, Abbas AM. Correlation between psychiatric impact of COVID-19 during pregnancy and fetal outcomes in Egyptian women. Psychiatry Res 2022; 317:114920. [PMID: 37732863 PMCID: PMC9597522 DOI: 10.1016/j.psychres.2022.114920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 12/15/2022]
Abstract
The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) was examined in 238 pregnant women with (n = 146) and without (n = 92) coronavirus disease 2019 (COVID-19) using the State-Trait Anxiety Inventory (STAI), Edinburgh Postnatal Depression Scale (EPDS), and PTSD Checklist for DSM-5 (PCL-5). Fetal outcomes in the same groups were evaluated using the Apgar score. Anxiety and depression scores were significantly higher in women with COVID-19 but PTSD scores were similar in both groups. Infection with COVID-19 was associated with a higher number of fetal deaths or an Apgar score <7. During the COVID-19 pandemic, approximately 46.6% of pregnant women had depression, 5.5% had PTSD, 64.3% had state anxiety, and 60.9% had trait anxiety. Except for PTSD, psychiatric problems and poor fetal outcomes were higher in women with COVID-19 than in those without COVID-19. Lastly, women with COVID-19 were more prone to have a fetus who died or had an Apgar score of <7.
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Affiliation(s)
- Gellan K Ahmed
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt; Department of Child & Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK.
| | - Safwat A Salman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled Elbeh
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Zaynap S Amer
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Redshaw M, Wynter K. Maternal mental health: Women’s voices and data from across the globe. BMC Pregnancy Childbirth 2022; 22:796. [PMID: 36307777 PMCID: PMC9614766 DOI: 10.1186/s12884-022-05064-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
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Takubo Y, Tsujino N, Aikawa Y, Fukiya K, Iwai M, Uchino T, Ito M, Akiba Y, Mizuno M, Nemoto T. Changes in thoughts of self-harm among postpartum mothers during the prolonged COVID-19 pandemic in Japan. Psychiatry Clin Neurosci 2022; 76:528-529. [PMID: 35831996 DOI: 10.1111/pcn.13451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Youji Takubo
- Department of Neuropsychiatry, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Psychiatry, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Naohisa Tsujino
- Department of Neuropsychiatry, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Psychiatry, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Yuri Aikawa
- Department of Psychiatry, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Kazuyo Fukiya
- Department of Psychiatry, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Momoko Iwai
- Department of Neuropsychiatry, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Takashi Uchino
- Department of Neuropsychiatry, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Megumu Ito
- Department of Obstetrics and gynecology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Yasuo Akiba
- Department of Obstetrics and gynecology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | | | - Takahiro Nemoto
- Department of Neuropsychiatry, Toho University Graduate School of Medicine, Tokyo, Japan
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Relationship between Antenatal Mental Health and Facial Emotion Recognition Bias for Children’s Faces among Pregnant Women. J Pers Med 2022; 12:jpm12091391. [PMID: 36143176 PMCID: PMC9500667 DOI: 10.3390/jpm12091391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022] Open
Abstract
The importance of identification of facial emotion recognition (FER) bias for a child’s face has been reinforced from the perspective of risk screening for future peripartum mental health problems. We attempted to clarify the relationship of FER bias for children’s faces with antenatal depression and bonding failure among pregnant women, taking into consideration their broad social cognitive abilities and experience in child raising. This study had a cross-sectional design, and participants were women in their second trimester of pregnancy. Seventy-two participants were assessed by the Edinburgh Postnatal Depression Scale (EPDS), the Mother-to-Infant Bonding Questionnaire (MIBQ), and a series of social cognitive tests. FER bias for a child’s face was assessed by Baby Cue Cards (BCC), and a larger number of disengagement responses suggest greater sensitivity to a child’s disengagement facial expressions. In a regression analysis conducted using EPDS as the dependent variable, a larger number of disengagement responses to the BCC (β = 0.365, p = 0.001) and the primipara status (β = −0.263, p = 0.016) were found to significantly contribute to antenatal depressive symptoms. Also, more disengagement responses to the BCC also significantly contributed to bonding failure as measured by the MIBQ (β = 0.234, p = 0.048). Maternal sensitivity to the child’s disengagement cues was associated with antenatal depressive symptoms and bonding failure more than the other social cognitive variables. The effects of FER bias on postpartum mental health and abusive behavior needs to be clarified by further longitudinal studies.
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Attitude and Level of COVID-19 Vaccination among Women in Reproductive Age during the Fourth Pandemic Wave: A Cross-Sectional Study in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116872. [PMID: 35682455 PMCID: PMC9180577 DOI: 10.3390/ijerph19116872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 12/04/2022]
Abstract
COVID-19 vaccination, apart from the sanitary regime, is the most efficient strategy to limit the spread of the SARS-CoV-2 virus and significantly reduce the severity of the disease following infection. A cross-sectional survey was conducted during the fourth wave of the COVID-19 pandemic among pregnant Polish women and women who have already given birth to evaluate the level and attitude to vaccination. Briefly, 1196 women (256 pregnant and 940 mothers) participated in the study; 68.0% of pregnant women and 66.2% of mothers declared that they had received COVID-19 vaccination. The most frequently stated reasons not to get vaccinated were possible adverse effects on the mother, fetus or breastfed child, post-vaccination complications and limited scientific evidence on the safety of the COVID-19 vaccine. The identified predictors of avoiding COVID-19 vaccination are young age, residing in small cities or rural areas, cohabitation, low anxiety level regarding SARS-CoV-2 infection, and little knowledge concerning maternal vaccine-induced immune protection delivered to offspring. Despite the unlimited access to COVID-19 vaccination, the declared level of vaccination is worryingly low. The knowledge concerning the benefits of vaccination to mothers and their offspring is not satisfactory and requires urgent educational action, particularly among young women living outside big cities and single motherhood.
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Adverse Mental Health Sequelae of COVID-19 Pandemic in the Pregnant Population and Useful Implications for Clinical Practice. J Clin Med 2022; 11:jcm11082072. [PMID: 35456165 PMCID: PMC9032065 DOI: 10.3390/jcm11082072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 02/05/2023] Open
Abstract
The COVID-19 pandemic has increased risk of disturbances in the functioning of everyday life, directly or indirectly has influenced the risk of mental disorders in the most vulnerable populations, including pregnant women. The aim of this study was to analyze adverse mental health effects in the pregnant population during the COVID-19 pandemic, investigate risk factors for adverse mental health outcomes, identify protective factors, and create practical implications for clinical practice, bearing in mind the need to improve perinatal mental healthcare during such pandemics. Qualitative research was conducted in the electronic databases PubMed and Web of Sciences for the keywords COVID-19, pregnancy, depression, anxiety, and telemedicine for relevant critical articles (n = 3280) published from 2020 until October 2021, outlining the outcomes of control studies, meta-analysis, cross-sectional studies, face-to-face evaluation survey studies, remotely administered survey studies, and observational studies regarding the main topic; all were evaluated. Mental health problems among pregnant women linked to the COVID-19 pandemic, in most cases, show symptoms of depression, anxiety, insomnia, and PTSD and may cause adverse outcomes in pregnancy and fetus and newborn development, even at later stages of life. Therefore, useful implications for clinical practice for improving the adverse mental health outcomes of pregnant women associated with the COVID-19 pandemic are highly desirable. Our research findings support and advocate the need to modify the scope of healthcare provider practice in the event of a disaster, including the COVID-19 pandemic, and may be implemented and adopted by healthcare providers as useful implications for clinical practice.
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