Postpartum mental illness during the COVID-19 pandemic: a population-based, repeated cross-sectional study

Women's mental health and COVID-19: increased vulnerability and inequalities

Introduction

The impact of COVID-19 on mental health has become a relevant object of research. Studies have demonstrated that women have experienced greater mental health challenges, highlighting the importance of public health systems to address women's specific needs.

Methods

This literature review explores the effects of the coronavirus pandemic on psychological distress among women, aiming to provide a comprehensive understanding of the subject and to explore how these research findings can guide public mental health care responses in crisis settings. A total of 131 studies were analyzed and four dimensions were discussed: study characteristics, factors impacting women's mental health in the pandemic setting, particularities of pregnancy and the postpartum period, and proposed interventions. Most studies exclusively addressed populations of adult women, predominantly during pregnancy and the postpartum period.

Results

Anxiety, depression, and stress were the most common outcomes. Lower education and income, preexisting mental health problems, and living alone or with children were risk factors for higher levels of anxiety and depression.

Discussion

A comprehensive care approach supported by public health policies and focused on intersectional factors, including race, socioeconomic status, and access to resources, is necessary to improve women's mental health care response in future crises.

Maternal Deaths by Suicide and Drug Overdose in Two Canadian Provinces; Retrospective Review

OBJECTIVES

To identify and review factors associated with maternal deaths by suicide and drug overdose in the Canadian Coroner and Medical Examiners Database, from 2017 to 2019.

METHODS

We identified potential maternal deaths in Ontario and British Columbia by searching the Canadian Coroner and Medical Examiners Database narratives of deaths to females 10 to 60 years old for pregnancy-related terms. Identified narratives were then qualitatively reviewed in quadruplicate to determine if they were maternal deaths by suicide or drug overdose, and to extract information on maternal characteristics, the manner of death, and factors associated with each death.

RESULTS

Of the 90 deaths identified in this study, 15 (16.7%) were due to suicide and 20 (22.2%) were due to a drug overdose. These deaths occurred in women of varying ages and across the pregnancy-postpartum period. Among the suicides, 10 were by hanging, and among the overdose-related deaths, 15 had fentanyl detected. Notably, 13 (37.1%) of the 35 deaths to suicide or drug overdose occurred beyond 42 days after pregnancy, 19 (54.3%) followed a miscarriage or induced abortion, and in 23 (65.7%) there was an established history of mental health illness. Substance use disorders were documented in 4 of the 15 suicides (26.7%), and 18 of the 20 overdose-related deaths (90.0%).

CONCLUSIONS

Suicide and drug overdose may contribute more to maternal deaths in Canada than previously realized. Programs are needed to identify women at risk of these outcomes and to intervene during pregnancy and beyond the conventional postpartum period.

Changes associated with the COVID-19 pandemic on postpartum screening results in Ontario, Canada: The healthy babies healthy children screening tool

BACKGROUND

Research on the impact of the COVID-19 pandemic on mothers/childbearing parents has mainly been cross-sectional and focused on psychological symptoms. This study examined the impact on function using ongoing, systematic screening of a representative Ontario sample.

METHODS

An interrupted time series analysis of repeated cross-sectional data from a province-wide screening program using the Healthy Babies Healthy Children (HBHC) tool assessed changes associated with the pandemic at the time of postpartum discharge from hospital. Postal codes were used to link to neighborhood-level data. The ability to parent or care for the baby/child and other psychosocial and behavioral outcomes were assessed.

RESULTS

The co-primary outcomes of inability to parent or care for the baby/child were infrequently observed in the pre-pandemic (March 9, 2019-March 15, 2020) and initial pandemic periods (March 16, 2020-March 23, 2021) (parent 209/63,006 (0.33%)-177/56,117 (0.32%), care 537/62,955 (0.85%)-324/56,086 (0.58%)). Changes after pandemic onset were not observed for either outcome although a significant (p = 0.02) increase in slope was observed for inability to parent (with questionable clinical significance). For secondary outcomes, worsening was only seen for reported complications during labor/delivery. Significant improvements were observed in the likelihood of being unable to identify a support person to assist with care, need of newcomer support, and concerns about money over time.

CONCLUSIONS

There were no substantive changes in concerns about ability to parent or care for children. Adverse impacts of the pandemic may have been mitigated by accommodations for remote work and social safety net policies.

Postpartum Mental Health and Perceptions of Discrimination Among Asian Fathers During the COVID-19 Pandemic

PURPOSE

The purpose of this study was twofold: (1) to examine the prevalence of postpartum depression and anxiety symptomatology among fathers of Asian descent living in North America during the COVID-19 pandemic, and (2) to identify the occurrences of online racial discrimination.

STUDY DESIGN AND METHODS

Using a cross-sectional design and convenience sampling methods, we recruited fathers online via social media sites (Facebook, Instagram) between March 12 and July 31, 2022. The Edinburgh Postnatal Depression Scale, General Anxiety Scale, and the Online Victimization Scale assessed mental health well-being and discrimination outcomes. Data were analyzed using descriptive statistics, two sample t-test, chi-square test of independence, and Pearson's correlation analysis.

RESULTS

Our sample included 61 fathers within 6 months postpartum living in the United States and Canada. Participants were on average 34 years old, married, and represented 17 Asian ethnic groups, including Asian Indian (41%), Filipino (11.3%), and Korean (8.1%). One-third of our participants (31.1%, n = 19) were at high risk of developing postpartum depression and scores of three (4.9%) fathers indicated they had clinically significant anxiety. Overall, 26.3% reported experiencing direct online racial discrimination and 65% reported occurrences of indirect online racial discrimination.

CLINICAL IMPLICATIONS

There was a high rate of depressive symptoms and occurrences of online racial discrimination among fathers of Asian descent living in North America. These rates are higher than the general perinatal population and further research is warranted to examine risk factors and preventive strategies among this unique paternal ethnic group.

Healthcare utilization before and during the COVID-19 pandemic among mothers and birthing parents with elevated levels of postpartum depression symptoms

Little is known about the healthcare utilization of mothers and birthing parents experiencing elevated levels of symptoms of postpartum depression (PPD), particularly during the COVID-19 pandemic. This study examined how healthcare utilization changed in these individuals during COVID-19. Individuals living in Ontario, Canada, with Edinburgh Postnatal Depression Scale Scores ≥ 10 were recruited into two separate randomized controlled trials of a 1-day intervention for PPD before (pre-COVID-19, n = 441) and during the pandemic (COVID-19, n = 287). Participants in both samples completed the same health resource use questionnaire, self-reporting the number of virtual and/or in-person visits to specific healthcare services over the three months preceding their treatment intervention. Use of medications, mental health care, primary care, hospital-based care, allied health care, and overall healthcare utilization were compared between the pre-COVID-19 and COVID-19 groups. While participants had higher levels of PPD symptoms during COVID-19, differences were not seen in the use of specific categories of care (e.g. mental health and primary care). However, before and after statistically adjusting for covariates, overall healthcare utilization decreased from an average of 9.5 visits prior to COVID-19 to 6.9 during COVID-19 (p < .001), a change that was at least partly contributed to by reductions in visits to allied health professionals (e.g. dentists and physiotherapists). Overall healthcare utilization decreased by 27 % in mothers and birthing parents seeking treatment for elevated levels of PPD symptoms during the COVID-19 pandemic in Ontario, Canada - despite higher levels of PPD symptoms - highlighting the need to support and address barriers to postpartum care.

Strategies to support maternal and early childhood wellness: insight from parent and provider qualitative interviews during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic resulted in rapid changes to the delivery of maternal and newborn care. Our aim was to gain an understanding from parents and healthcare professionals (HCPs) of how the pandemic and associated public health restrictions impacted the peripartum and postpartum experience, as well as longer-term health and well-being of families.

DESIGN

Qualitative study through focus groups.

SETTING

Ontario, Canada.

PARTICIPANTS

HCPs and parents who had a child born during the COVID-19 pandemic.

INTERVENTIONS

Semistructured interview guide, with questions focused on how the pandemic impacted their care/their ability to provide care, and strategies to improve care and support now or in future situations with similar healthcare restrictions.

OUTCOME MEASURES

Thematic analysis was used to describe participant experiences and recommendations.

RESULTS

We included 11 HCPs and 15 parents in 6 focus groups. Participants described their experiences as 'traumatic', with difficulties in accessing prenatal and postpartum services, and feelings of distress and isolation. They also noted delays in speech and development in children born during the pandemic. Key recommendations included the provision of partner accompaniment throughout the course of care, expansion of available services for young families (particularly postpartum), and special considerations for marginalised groups, including access to technology for virtual care or the option of in-person visits.

CONCLUSIONS

Our findings may inform the development of healthcare system and organisational policies to ensure the provision of maternal and newborn care in the event of future public health emergencies. Of primary importance to the participants was the accommodation of antenatal, intrapartum and postpartum partner accompaniment, and the provision of postpartum services.

Postpartum Psychosis: A Review of Risk Factors, Clinical Picture, Management, Prevention, and Psychosocial Determinants

Postpartum psychosis is rare, but is a serious clinical and social problem. On its own, it is not included in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) or ICD-10 (International Statistical Classification of Diseases and Related Health Problems) as a disease entity, and current diagnostic criteria equate it with other psychoses. This poses a serious legal problem and makes it difficult to classify. The disorder is caused by a complex combination of biological, environmental, and cultural factors. The exact pathophysiological mechanisms of postpartum psychosis remain very poorly understood. There is a need for further research and increased knowledge of the medical sector in the prevention and early detection of psychosis to prevent stigmatization of female patients during a psychiatric episode. It is necessary to regulate its position in the DSM5 and ICD-10. Attention should be paid to the social education of expectant mothers and their families. This article aims to review the current status of risk factors, prevention, and management of postpartum psychosis.

Sex differences among children, adolescents and young adults for mental health service use within inpatient and outpatient settings, before and during the COVID-19 pandemic: a population-based study in Ontario, Canada

OBJECTIVES

The pandemic and public health response to contain the virus had impacts on many aspects of young people's lives including disruptions to daily routines, opportunities for social, academic, recreational engagement and early employment. Consequently, children, adolescents and young adults may have experienced mental health challenges that required use of mental health services. This study compared rates of use for inpatient and outpatient mental health services during the pandemic to pre-pandemic rates.

DESIGN

Population-based repeated cross-sectional study.

SETTING

Publicly delivered mental healthcare in primary and secondary settings within the province of Ontario, Canada.

PARTICIPANTS

All children 6-12 years of age (n=2 043 977), adolescents 13-17 years (n=1 708 754) and young adults 18-24 years (n=2 286 544), living in Ontario and eligible for provincial health insurance between March 2016 and November 2021.

PRIMARY OUTCOME MEASURES

Outpatient mental health visits to family physicians and psychiatrists for: mood and anxiety disorders, alcohol and substance abuse disorders, other non-psychotic mental health disorders and social problems. Inpatient mental health visits to emergency departments and hospitalisations for: substance-related and addictive disorders, anxiety disorders, assault-related injuries, deliberate self-harm and eating disorders. All outcomes were analysed by cohort and sex.

RESULTS

During the pandemic, observed outpatient visit rates were higher among young adults by 19.01% (95% CI: 15.56% to 22.37%; 209 vs 175 per 1000) and adolescent women 24.17% (95% CI: 18.93% to 29.15%; 131 vs 105 per 1000) for mood and anxiety disorders and remained higher than expected. Female adolescents had higher than expected usage of inpatient care for deliberate self-harm, eating disorders and assault-related injuries.

CONCLUSIONS

Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.

Utilization of physician mental health services by birthing parents with young children during the COVID-19 pandemic: a population-based, repeated cross-sectional study

BACKGROUND

The COVID-19 pandemic and nonpharmaceutical interventions that reduced the spread of infection had impacts on social interaction, schooling and employment. Concerns have been raised about the impact of these disruptions on the mental health of high-risk groups, including birthing parents of young children.

METHODS

This population-based, repeated cross-sectional study used health administrative databases in Ontario, Canada, to link children to birth parents and to measure subsequent mental health visits of birthing parents of younger (age 0-5 yr) and school-aged (6-12 yr) children. We used a repeated cross-sectional study design to estimate expected rates for visits to physicians for mental health diagnoses, based on prepandemic trends (March 2016-February 2020), and to compare those to observed visit rates during the March 2020-November 2021 period of the pandemic.

RESULTS

We identified 2 cohorts: 986 870 birthing parents of younger children and 1 012 997 birthing parents of school-aged children. In both cohorts, observed visit rates were higher than expected in the June 2020-August 2020 quarter (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI] 1.10-1.16; and IRR 1.10, 95% CI 1.07-1.13, respectively), peaked in December 2020-February 2021 (IRR 1.24, 95% CI 1.20-1.27; and IRR 1.20, 95% CI 1.16-1.23) and remained higher than expected in September 2021-November 2021 (IRR 1.12, 95% CI 1.08-1.16; and IRR 1.09, 95% CI 1.06-1.13). The increases were driven mostly by visits for mood and anxiety disorders, and trends in increases were similar across physician type, birthing-parent age and deprivation quintile.

INTERPRETATION

The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.

The pandemic experiences of Ontario perinatal providers: a qualitative study

BACKGROUND

The COVID-19 pandemic has produced widespread disruptions for healthcare systems across Canada. Perinatal care in Ontario, Canada was subject to province-wide public health restrictions, reallocation of hospital beds and human health resources. To better understand the impacts of the pandemic on Ontario perinatal care, this study explored the perspectives of perinatal care providers about their clinical COVID-19 pandemic experiences.

METHODS

Semi-structured key informant virtual interviews were conducted between August 2021 and January 2022 with 15 Ontario-based perinatal care providers. Recorded interviews were transcribed, and thematic content analysis used to identify major themes and subthemes.

RESULTS

Participants were mainly women, practicing in Eastern and Central Ontario as health providers (obstetricians, nurses, midwives), allied regulated health professionals (social worker, massage therapist), and perinatal support workers (doula, lactation consultant). Major themes and subthemes were identified inductively as follows: (1) Impacts of COVID-19 on providers (psychosocial stress, healthcare system barriers, healthcare system opportunities); (2) Perceived impacts of COVID-19 on pregnant people (psychosocial stress, amplification of existing healthcare barriers, influences on reproductive decision making; minor theme- social and emotional support roles); (3) Vaccine discourse (provider empathy, vaccines and patient family dynamics, minor themes- patient vaccine hesitancy, COVID-19 misinformation); and (4) Virtual pregnancy care (benefits, disadvantages, adaptation of standard care practices).

CONCLUSIONS

Perinatal care providers reported significant stress and uncertainty caused by the COVID-19 pandemic and evolving hospital protocols. Providers perceived that their patients were distressed by both the pandemic and related reductions in pregnancy healthcare services including hospital limits to support companion(s). Although virtual pregnancy care impaired patient-provider rapport, most providers believed that the workflow efficiencies and patient convenience of virtual care is beneficial to perinatal healthcare.

Pandemic-induced increase in adjustment disorders among postpartum women in Germany

BACKGROUND

The current paper analyzed the effect of the pandemic-induced lockdown on maternal mental health during the first 12 postpartum weeks in Germany.

METHODS

In this cohort study, we compared the participants' anamnestic backgrounds and the results of psychological tests, measuring stress levels, depressive symptoms and attachment. The 327 participants were divided into two groups with one representing the "pre-COVID" sample and the other the "lockdown" sample. We performed multiple comparisons, investigating the distribution of diagnoses and the correlating risk profiles between the two cohorts.

RESULTS

Our analysis showed a significant difference between the two cohorts, with a 13.2% increase in the prevalence of adjustment disorders (AD), but not postpartum depression (PPD), in the first 12 weeks postpartum. However, during the pandemic, women with AD had fewer risk factors compared to their pre-pandemic counterparts. In the "lockdown" cohort, a tendency toward higher stress and lower mother-child attachment was observed in AD.

CONCLUSIONS

In sum, we observed some negative impact of the pandemic on maternal mental health. The lockdown might have contributed to an increase in the number of cases involving AD in the postpartum period. The prevalence of PPD (ca. 6-10%), on the other hand, was not affected by the lockdown. Thus, the effect of COVID-19 on maternal mental health might not, after all, have been as severe as assumed at the beginning of the pandemic.

Screening for postpartum depression and risk of suicidality with obstetrical patients: a cross-sectional survey

BACKGROUND

Pregnancy is a vulnerable time where the physical and social stress of the COVID-19 pandemic affects psychological health, including postpartum depression (PPD). This study is designed to estimate the prevalence and correlates of PPD and risk of suicidality among individuals who gave birth during the COVID-19 pandemic.

METHODS

We surveyed individuals who gave birth at The Ottawa Hospital and were ≥ 20 days postpartum, between March 17 and June 16, 2020. A PPD screen consisted of a score ≥ 13 using the Edinburgh Postnatal Depression Scale. A score of 1, 2, or 3 on item 10 ("The thought of harming myself has occurred to me") indicates risk of suicidality. If a participant scores greater than ≥ 13 or ≥ 1 on item 10 they were flagged for PPD, the Principal Investigator (DEC) was notified within 24 h of survey completion for a chart review and to assure follow-up. Modified Poisson multivariable regression models were used to identify factors associated with PPD and risk of suicidality using adjusted risk ratios (aRR) and 95% confidence intervals (CI).

RESULTS

Of the 216 respondents, 64 (30%) screened positive for PPD and 17 (8%) screened positive for risk of suicidality. The maternal median age of the total sample was 33 years (IQR: 30-36) and the infant median age at the time of the survey was 76 days (IQR: 66-90). Most participants reported some form of positive coping strategies during the pandemic (97%) (e.g. connecting with friends and family, exercising, getting professional help) and 139 (64%) reported negative coping patterns (e.g. over/under eating, sleep problems). In total, 47 (22%) had pre-pregnancy anxiety and/or depression. Negative coping (aRR:2.90, 95% CI: 1.56-5.37) and pre-existing anxiety/depression (aRR:2.03, 95% CI:1.32-3.11) were associated with PPD. Pre-existing anxiety/depression (aRR:3.16, 95% CI:1.28-7.81) was associated with risk of suicidality.

CONCLUSIONS

Almost a third of participants in this study screened positive for PPD and 8% for risk of suicidality. Mental health screening and techniques to foster positive coping skills/strategies are important areas to optimize postpartum mental health.

Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps

Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.

Postpartum people's experiences of and responses to the COVID-19 pandemic during the first year of the pandemic: A descriptive qualitative study

BACKGROUND

Most evidence on the impact of pandemic on perinatal population's experiences has reported such effects in a portion of the pandemic.

OBJECTIVES

The aim of this study was to understand the postpartum people's experiences of and responses to the coronavirus disease 2019 pandemic during the first year and to identify their health care needs.

DESIGN

This is a descriptive qualitative study.

METHODS

This study was conducted in British Columbia, Canada, between March 2020 and April 2021. Participants (N = 268) were at 4 months postpartum and were recruited as part of the Pregnancy Specific Anxiety Tool study through prenatal care clinics and classes, community laboratory services and social media. Qualitative data were obtained using six online open-ended questions and were analysed using thematic analysis.

RESULTS

Findings were grouped under five central themes: protecting baby (with three categories including hypervigilance, constant decision-making to find balance and developmental issues); psychological adjustments (with three categories including coping, anxiety and grief); experience of isolation and lack/loss of support (with two categories including isolation and loss of expected support); unexpected interruptions and life events (with four categories including interrupted maternity leave, unexpected changes/life events, positive impacts and interruption in health care services); and perceived postpartum care needs (with five categories including in-person visits, allowing support persons, providing information/education/support groups, mental health and social support and pro-active check-ins).

CONCLUSION

Several impacts of the pandemic persisted throughout the first year, particularly isolation and lack of support. These findings can inform responsive health care services to address the emerging needs of postpartum people throughout the pandemic.

Perinatal mental health and COVID-19: Navigating a way forward

The COVID-19 pandemic and its aftermath have increased pre-existing inequalities and risk factors for mental disorders in general, but perinatal mental disorders are of particular concern. They are already underdiagnosed and undertreated, and this has been magnified by the pandemic. Access to services (both psychiatric and obstetric) has been reduced, and in-person contact has been restricted because of the increased risks. Rates of perinatal anxiety and depressive symptoms have increased. In the face of these challenges, clear guidance in perinatal mental health is needed for patients and clinicians. However, a systematic search of the available resources showed only a small amount of guidance from a few countries, with a focus on the acute phase of the pandemic rather than the challenges of new variants and variable rates of infection. Telepsychiatry offers advantages during times of restricted social contact and also as an additional route for accessing a wide range of digital technologies. While there is a strong evidence base for general telepsychiatry, the particular issues in perinatal mental health need further examination. Clinicians will need expertise and training to navigate a hybrid model, flexibly combining in person and remote assessments according to risk, clinical need and individual patient preferences. There are also wider issues of care planning in the context of varying infection rates, restrictions and vaccination access in different countries. Clinicians will need to focus on prevention, treatment, risk assessment and symptom monitoring, but there will also need to be an urgent and coordinated focus on guidance and planning across all organisations involved in perinatal mental health care.

The impact of the COVID-19 pandemic on stress and other psychological factors in pregnant women giving birth during the first wave of the pandemic

BACKGROUND

The onset of mental illness such as depression and anxiety disorders in pregnancy and postpartum period is common. The coronavirus induced disease 2019 (COVID-19) pandemic and the resulting public policy responses represent an exceptional situation worldwide and there are hints for adverse psychosocial impact, hence, the study of psychological effects of the pandemic in women during hospitalization for delivery and in the postpartum period is highly relevant.

METHODS

Patients who gave birth during the first wave of the COVID-19 pandemic in Germany (March to June 2020) at the Department of Obstetrics and Gynecology, University of Würzburg, Germany, were recruited at hospital admission for delivery. Biosamples were collected for analysis of SARS-CoV-2 infection and various stress hormones and interleukin-6 (IL-6). In addition to sociodemographic and medical obstetric data, survey questionnaires in relation to concerns about and fear of COVID-19, depression, stress, anxiety, loneliness, maternal self-efficacy and the mother-child bonding were administered at T1 (delivery stay) and T2 (3-6 months postpartum).

RESULTS

In total, all 94 recruited patients had a moderate concern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at T1 with a significant rise at T2. This concern correlated with low to low-medium general psychosocial stress levels and stress symptoms, and the women showed a significant increase of active coping from T1 to T2. Anxiety levels were low and the Edinburgh Postnatal Depression Scale showed a medium score of 5 with a significant (T1), but only week correlation with the concerns about SARS-CoV-2. In contrast to the overall good maternal bonding without correlation to SARS-CoV-2 concern, the maternal self-efficiency correlated negatively with the obstetric impairment caused by the COVID-19 pandemic.

CONCLUSION

Obstetric patients` concerns regarding SARS-CoV-2 and the accompanying pandemic increased during the course of the pandemic correlating positively with stress and depression. Of note is the increase in active coping over time and the overall good mother-child-bonding. Maternal self-efficacy was affected in part by the restrictions of the pandemic. Clinical trial registration DRKS00022506.

Telemedicine in perinatal mental health: perspectives

Background: The prevalence of perinatal mood and anxiety disorders has significantly increased with the COVID-19 pandemic. In parallel, the pandemic has caused a major shift in delivery of care to telemedicine.Purpose: This article aimed to discuss the different advantages and disadvantages of telemedicine for perinatal mental health. Telemedicine has significant benefits for perinatal mental health patients, including increased accessibility to specialized care, direct observation of child-parent interactions in their home environment, and facilitation of collaborative work between obstetrical providers and psychiatrists. Alternatively, telemedicine may impede recovery and contribute to an increase in social isolation. The use of telemedicine by obstetrical care providers may also contribute to a reduction in screening and identification of these disorders.Conclusion: A hybrid model of in-person and telemedicine delivery of care may serve as a durable compromise solution for these women and their families.

Temporal trends of suicide-related non-traumatic out-of-hospital cardiac arrest characteristics and outcomes with the COVID-19 pandemic

Background

Jurisdictions have reported COVID-19-related increases in the incidence and mortality of non-traumatic out-of-hospital cardiac arrest (OHCA). We hypothesized that changes in suicide incidence during the COVID-19 pandemic may have contributed to these changes. We investigated whether the COVID-19 pandemic was associated with changes in the: (1) incidence of suicide-related OHCA, and (2) characteristics and outcomes of such cases.

Methods

We used the provincial British Columbia Cardiac Arrest Registry, including non-traumatic emergency medical system (EMS)-assessed OHCA, to compare suicide-related OHCA (defined as clear self-harm or a priori communication of intent) one-year prior to, and one year after, the start of the COVID-19 pandemic (March 15, 2020). We calculated differences in incidence (with 95% CI), overall and within subgroups of mechanism (hanging, suffocation, poisoning, or unclear mechanism), and in case characteristics and hospital-discharge favourable neurological outcomes (CPC 1–2).

Results

Of 13,785 EMS-assessed OHCA, we included 274/6430 (4.3%) pre-pandemic and 221/7355 (3.0%) pandemic-period suicide-related cases. The median age was 43 years (IQR 30–57), 157 (32%) were female, and 7 (1.4%) survived with favourable neurological status. Suicide-related OHCA incidence decreased from 5.4 pre-pandemic to 4.3 per 100 000 person-years (-1.1, 95% CI −2.0 to −0.28). Hanging-related OHCA incidence also decreased. Patient characteristics and hospital discharge outcomes between periods were similar.

Conclusion

Suicide-related OHCA incidence decreased with the COVID-19 pandemic and we did not detect changes in patient characteristics or outcomes, suggesting that suicide is not a contributor to increases in COVID-related OHCA incidence or mortality. Overall suicide-related OHCA outcomes in both time periods were poor.

Mental Health in Obstetric Patients and Providers During the COVID-19 Pandemic

Psychiatric morbidity is the most common childbirth complication with 1 in 5 women experiencing a perinatal mood or anxiety disorder. The cost of this psychiatric morbidity is pervasive, contributing to devastating maternal health, child developmental, and economic consequences. The coronavirus disease 2019 (COVID-19) pandemic, and associated changes to perinatal experiences, resulted in profound psychological reactions including increased anxiety, depression, stress disorders, and sleep disturbance, further impacting obstetric patients. Providers' mental health has been challenged by moral injury and shared trauma. This article reviews mental health outcomes in regard to the COVID-19 pandemic for obstetric patients and their providers.

Assessment of Canadian perinatal mental health services from the provider perspective: Where can we improve?

PURPOSE

Perinatal mental health disorders are common, and rates have increased during the COVID-19 pandemic. It is unclear where providers may improve perinatal mental health care, particularly in countries lacking national guidelines, such as Canada.

METHODS

A cross-sectional survey of perinatal health providers was conducted to describe the landscape of perinatal mental health knowledge, screening, and treatment practices across Canada. Providers were recruited through listservs, social media, and snowball sampling. Participants completed an online survey that assessed their perinatal mental health training, service provision types, their patient wait times, and treatment barriers, and COVID-19 pandemic-related impacts.

RESULTS

A total of 435 providers completed the survey, including physicians, midwives, psychologists, social workers, nurses, and allied non-mental health professionals. Most (87.0%) did not have workplace mandated screening for perinatal mental illness but a third (66%) use a validated screening tool. Many (42%) providers stated their patients needed to wait more than 2 months for services. More than half (57.3%) reported they did not receive or were unsure if they received specialized training in perinatal mental health. Most (87.0%) indicated there were cultural, linguistic, and financial barriers to accessing services. Over two-thirds (69.0%) reported the COVID-19 pandemic reduced access to services.

CONCLUSION

Survey findings reveal significant gaps in training, screening tool use, and timely and culturally safe treatment of perinatal mental health concerns. There is critical need for coordinated and nationally mandated perinatal mental health services in Canada to improve care for pregnant and postpartum people.

Perceived vulnerability to immigration policies among postpartum Hispanic/Latina women in the MADRES pregnancy cohort before and during the COVID-19 pandemic

INTRODUCTION AND OBJECTIVES

Research suggests that perceived immigration policy vulnerability has important health implications. Coupled with the mental and physical stressors accompanying the postpartum period and a growing awareness of the discrimination and structural racism experienced by marginalized communities globally, the coronavirus disease 2019 period may have exacerbated stress among vulnerable populations, specifically postpartum Hispanic/Latina women. This study evaluated perceived immigration policy vulnerability (i.e. discrimination, social isolation, and family threats) in early postpartum Hispanic/Latina women in Los Angeles before and during the coronavirus disease 2019 pandemic.

METHODS

The Perceived Immigration Policy Effects Scale (PIPES) was administered cross-sectionally at 1 month postpartum to 187 Hispanic/Latina women in the MADRES cohort. Respondents between September 2018 and March 2020 were classified as "pre-pandemic" (N = 128), between March 2020 and July 2020 as "early pandemic" (N = 38), and between August 2020 and November 2021 as "later pandemic" (N = 21). Average PIPES subscale scores were dichotomized into "higher" and "lower" groups (⩽median, >median) and logistic regression models were performed.

RESULTS

Approximately half of participants had incomes of <$50,000 (50.3%) and were Latin American born (54.6%). After adjusting for age, nativity, education, income, postpartum distress, and employment status, early pandemic respondents had 5.05 times the odds of a higher score on the perceived discrimination subscale (95% CI: 1.81, 14.11), 6.47 times the odds of a higher score on the social isolation subscale (95% CI: 2.23, 18.74), 2.66 times the odds of a higher score on the family threats subscale (95% CI: 0.97, 7.32), and 3.36 times the odds of a higher total score (95% CI: 1.19, 9.51) when compared to pre-pandemic respondents. There were no significant subscale score differences between later pandemic and pre-pandemic periods.

CONCLUSION

Higher perceived immigration policy vulnerability was reported among postpartum women during the early coronavirus disease 2019 pandemic versus pre-pandemic periods. This suggests greater social inequities during the early pandemic period.

"There is always a waitlist": The experiences of perinatal women randomized to a waitlist condition in a trial evaluating a novel online self-directed intervention for perinatal anxiety

Background

Pregnant and postpartum women are at a heightened risk for the development or worsening of mental health problems, with elevated rates of mood and anxiety disorders noted across studies. Timely access to mental health supports is critical during the perinatal period (spanning pregnancy to 1 year postpartum), to mitigate potential negative impacts on mother and child. In general adult populations, a small body of research has highlighted the association between being waitlisted for mental health services with a deterioration in mental health. Given the influx of changes experienced in the perinatal period, this population may face unique challenges around being waitlisted. There is a lack of research exploring the experiences of perinatal women waitlisted for psychological services. The current study seeks to understand the experiences of perinatal women randomized to the waitlist condition of a randomized controlled trial.

Methods

N = 20 participants (4 pregnant, 16 postpartum) from Central Canada who were enrolled in a novel online self-directed intervention for perinatal anxiety completed a virtual qualitative interview concerning their experience during the 6-week waitlist period for this randomized controlled trial. Interviews were audio-recorded, transcribed, and analyzed according to reflexive thematic analysis.

Results

Seven main themes were identified, depicting the waitlist experiences of perinatal participants: (a) "There is always a waitlist" (sub-themes: service availability, need to seek out services pre-emptively); (b) Timing of support access is vital during the perinatal period (sub-themes: prenatal, postpartum); (c) Responses to being waitlisted (sub-themes: disappointment, neutral, relief, "there's probably somebody that needs it more than I do"); (d) Identification of helpful supports during the waitlist period (sub-themes: formal supports, informal supports); (e) Connections with research team (sub-themes: communication, resource provision); (f) Impact of waitlist experience on desire to start program (sub-themes: excitement, "out of sight, out of mind," nervousness); and (g) Improving the waitlist experience (sub-themes: communication, resource provision, triaging).

Discussion

Findings highlight the need for timely access to mental health supports during the perinatal period and offer several recommendations for improving the waitlist experience, including providing more frequent waitlist status updates, providing more direct access to intermediate interventions, and triaging patients based on clinical need.

The psychological impact of the COVID-19 pandemic and a SARS-CoV-2 testing programme on obstetric patients and healthcare workers

Objectives:

The aim of this study was to describe the psychological impact of the COVID-19 pandemic and the specific impact of a universal SARS-CoV-2 testing programme on obstetric patients and healthcare workers at The Ottawa Hospital.

Methods:

This was a follow-up survey study of obstetric healthcare workers and then-pregnant patients who participated in a SARS-CoV-2 testing programme conducted in The Ottawa Hospital obstetrical triage units from 19 October to 17 November 2020. Surveys explored the effects of the COVID-19 pandemic and the testing programme on participants’ psychological well-being. Responses were collected from April to September 2021. Descriptive summary statistics were calculated for both groups.

Results:

During hospitalization for delivery, obstetric patients (n = 143) worried about giving COVID-19 to their new baby (88.11%), catching COVID-19 (83.22%), and giving COVID-19 to their partner (76.22%). Patients felt relief at being tested for COVID-19 during the universal testing programme (24.65%) and at getting their results (28.87%). Patients also believed that universal SARS-CoV-2 testing was a good way to slow COVID-19 spread (79.72%), reduce anxiety (75.52%), and increase relief (76.22%). In addition, patients felt good about participating in research that could help others (91.61%). Among obstetric healthcare workers (n = 94), job satisfaction decreased and job stress increased during the COVID-19 pandemic. The universal testing programme led to minor increases in healthcare worker job stress and burden, particularly among nurses, but the majority (85.23%) believed it was a valuable research initiative.

Conclusion:

The COVID-19 pandemic has had a negative psychological impact on obstetric patients and healthcare workers. Universal SARS-CoV-2 testing was generally viewed favourably and may serve as an effective strategy for estimating COVID-19 prevalence without adding undue stress onto patients and healthcare workers during the pandemic.

"COVID affected us all:" the birth and postnatal health experiences of resettled Syrian refugee women during COVID-19 in Canada

BACKGROUND

Prior to COVID-19, postnatal resettled refugee women in Canada reported barriers to healthcare and low levels of social support, contributing to maternal health morbidities. The COVID-19 pandemic appears to be further exacerbating health inequities for marginalized populations. The experiences of resettled refugee women are not fully known.

AIM

To understand Syrian refugee women's experiences accessing postnatal healthcare services and supports during the COVID-19 pandemic.

METHODS

Semi-structured, virtual interviews were conducted with eight resettled Syrian refugee women living in Nova Scotia (Canada) who were postnatal between March and August 2020. Data analysis was informed by constructivist grounded theory.

FINDINGS

Three themes emerged: "the impacts of COVID-19 on postnatal healthcare;" "loss of informal support;" and "grief and anxiety." Women experienced difficult healthcare interactions, including socially and physically isolated deliveries, challenges accessing in-person interpreters, and cancelled or unavailable in-home services (e.g., public health nurse and doula visits). Increased childcare responsibilities and limited informal supports due to pandemic restrictions left women feeling overwhelmed and exhausted. Stay-at-home orders resulted in some women reporting feelings of isolation and loss, as they were unable to share in person postnatal moments with friends and family, ultimately impacting their mental wellness.

CONCLUSIONS

COVID-19 and associated public health restrictions had significant impacts on postnatal Syrian refugee women. Data presented in this study demonstrated the ways in which the pandemic environment and related restrictions amplified pre-existing barriers to care and postnatal health inequalities for resettled refugee women-particularly a lack of postnatal informal supports and systemic barriers to care.

Barriers and Facilitators to Resuming In-Person Psychotherapy with Perinatal Patients amid the COVID-19 Pandemic: A Multistakeholder Perspective

During the COVID-19 pandemic, outpatient psychotherapy transitioned to telemedicine. This study aimed to examine barriers and facilitators to resuming in-person psychotherapy with perinatal patients as the pandemic abates. We conducted focus group and individual interviews with a sample of perinatal participants (n = 23), psychotherapy providers (n = 28), and stakeholders (n = 18) from Canada and the U.S. involved in the SUMMIT trial, which is aimed at improving access to mental healthcare for perinatal patients with depression and anxiety. Content analysis was used to examine perceived barriers and facilitators. Reported barriers included concerns about virus exposure in a hospital setting (77.8% stakeholders, 73.9% perinatal participants, 71.4% providers) or on public transportation (50.0% stakeholders, 26.1% perinatal participants, 25.0% providers), wearing a mask during sessions (50.0% stakeholders, 25.0% providers, 13.0% participants), lack of childcare (66.7% stakeholders, 46.4% providers, 43.5% perinatal participants), general transportation barriers (50.0% stakeholders, 47.8% perinatal participants, 25.0% providers), and the burden of planning and making time for in-person sessions (35.7% providers, 34.8% perinatal participants, 27.8% stakeholders). Reported facilitators included implementing and communicating safety protocols (72.2% stakeholders, 47.8% perinatal participants, 39.3% providers), conducting sessions at alternative or larger locations (44.4% stakeholders, 32.1% providers, 17.4% perinatal participants), providing incentives (34.8% perinatal participants, 21.4% providers, 11.1% stakeholders), and childcare and flexible scheduling options (31.1% perinatal participants, 16.7% stakeholders). This study identified a number of potential barriers and illustrated that COVID-19 has fostered and amplified barriers. Future interventions to facilitate resuming in-person sessions should focus on patient-centered strategies based on empathy regarding ongoing risk-aversion among perinatal patients despite existing safety protocols, and holistic thinking to make access to in-person psychotherapy easier and more accessible for perinatal patients.

Coronavirus Disease 2019 and Human Reproduction: A Changing Perspective

Since the outbreak of severe acute respiratory coronavirus 2 (SARS-CoV-2), the coronavirus disease 2019 has had a wide range of effects on human health. This paper summarizes the data related to the effects of the SARS-CoV-2 infection on human reproduction. Both the male and female reproductive tract express high levels of receptors and proteins needed for viral cell entry. There is presently no evidence that gametes are affected by the infection. Male fertility may be temporarily reduced due to inflammatory responses following infection. The endometrium is highly susceptible to SARS-CoV-2 cell entry; however, it remains unclear whether this could alter receptivity and embryo implantation. Menstrual cycle changes were reported in women who experienced severe infection; however, they tended to be reversible. For couples undergoing assisted reproduction treatment, the pandemic led to a significant psychological burden, with changes in lifestyle that could directly affect the success of the treatment. Human reproduction societies recommend screening all patients prior to cycle initiation and avoiding treatment of women with severe comorbidities until the pandemic is under control. Finally, for pregnant women, it is expected that the infection is more severe in women in the third trimester and in those with comorbidities. Those who are symptomatic for SARS-CoV-2 are more likely to have increased rates of prematurity and intrapartum fetal distress than those who are asymptomatic. Vertical transmission cannot be completely ruled out, but neonatal infection rates are low. Vaccination appears to be safe and is indicated for use in pregnant and lactating women because the benefits outweigh the risks.

Women’s Preferences and Design Recommendations for a Postpartum Depression Psychoeducation Intervention: A User Involvement Study (Preprint)

Background

Objective

Methods

Results

Conclusions