Contributions of COVID-19 Pandemic-Related Stressors to Racial and Ethnic Disparities in Mental Health During Pregnancy

Addressing bias in preterm birth research: The role of advanced imputation techniques for missing race and ethnicity in perinatal health data

OBJECTIVES

To evaluate the effectiveness of Bayesian Improved Surname Geocoding (BISG) and Bayesian Improved First Name Surname Geocoding (BIFSG) in estimating race and ethnicity, and how they influence odds ratios for preterm birth.

METHODS

We analyzed hospital birth admission electronic health records (EHR) data (N = 9985). We created two simulation sets with 40 % of race and ethnicity data missing randomly or more likely for non-Hispanic black birthing people who had preterm birth. We calculated C-statistics to evaluate how accurately BISG and BIFSG estimate race and ethnicity. We examined the association between race and ethnicity and preterm birth using logistic regression and reported odds ratios (OR).

RESULTS

BISG and BIFSG showed high accuracy for most racial and ethnic categories (C-statistics = 0.94-0.97, 95 % confidence intervals [CI] = 0.92-0.97). When race and ethnicity were not missing at random, BISG (OR = 1.25, CI = 0.97-1.62) and BIFSG (OR = 1.38, CI = 1.08-1.76) resulted in positive estimates mirroring the true association (OR = 1.68, CI = 1.34-2.09) for Non-Hispanic Black birthing people, while traditional methods showed contrasting estimates (Complete case OR = 0.62, CI = 0.41-0.94; multiple imputation OR = 0.63, CI = 0.40-0.98).

CONCLUSIONS

BISG and BIFSG accurately estimate missing race and ethnicity in perinatal EHR data, decreasing bias in preterm birth research, and are recommended over traditional methods to reduce potential bias.

Effects of Two Group Prenatal Care Interventions on Mental Health: An RCT

INTRODUCTION

Perinatal depression and anxiety cost the U.S. health system $102 million annually and result in adverse health outcomes. Research supports that cognitive behavioral therapy improves these conditions, but barriers to obtaining cognitive behavioral therapy have prevented its success in pregnant individuals. In this study, the impact of a cognitive behavioral therapy-based intervention on anxiety, depression, stress, healthy lifestyle beliefs, and behaviors in pregnant people was examined.

STUDY DESIGN

This study used a 2-arm RCT design, embedded in group prenatal care, with one arm receiving a cognitive behavioral therapy-based Creating Opportunities for Personal Empowerment program and the other receiving health promotion content.

SETTING/PARTICIPANTS

Black and Hispanic participants (n=299) receiving prenatal care from 2018 to 2022 in New York and Ohio who screened high on 1 of 3 mental health measures were eligible to participate.

INTERVENTION

Participants were randomized into the manualized Creating Opportunities for Personal Empowerment cognitive behavioral therapy-based program, with cognitive behavioral skill-building activities delivered by advanced practice nurses in the obstetrical setting.

MAIN OUTCOME MEASURES

Outcomes included anxiety, depression, and stress symptoms using valid and reliable tools (Generalized Anxiety Disorder scale, Edinburgh Postnatal Depression Scale, and Perceived Stress Scale). The Healthy Lifestyle Beliefs and Behaviors Scales examined beliefs about maintaining a healthy lifestyle and reported healthy behaviors.

RESULTS

There were no statistically significant differences between groups in anxiety, depression, stress, healthy beliefs, and behaviors. There were significant improvements in all measures over time. There were statistically significant decreases in anxiety, depression, and stress from baseline to intervention end, whereas healthy beliefs and behaviors significantly increased.

CONCLUSIONS

Both cognitive behavioral therapy and health promotion content embedded in group prenatal care with advanced practice nurse delivery improved mental health and healthy lifestyle beliefs and behaviors at a time when perinatal mood generally worsens.

TRIAL REGISTRATION

This study is registered with clinicaltrials.gov NCT03416010.

The role of doulas in supporting perinatal mental health - a qualitative study

Objective

The perinatal period presents several opportunities to identify and treat perinatal mental health and substance use disorders by integrating into existing care pathways. We aimed to examine the role of birth doulas in supporting their clients' perinatal mental health.

Methods

Thematic content analysis of focus groups with doulas, and interviews with doula clients was used to characterize the doula-client relationship, investigate whether and how doulas provide mental health and substance use support, and identify barriers and recommendations for doulas to support their clients' mental health. Participants were doula clients from communities underserved due to race, income, language and culture.

Results

Doulas and clients reported positive relationships, supported by congruence in culture, language, and lived experiences. Doulas varied in their confidence in identifying perinatal mental health problems, though most agreed that doulas could support their clients' mental health to different degrees. Barriers to engaging in perinatal mental health treatments included low perceived need and socio-economic burden.

Conclusions

With adequate support and training, doulas can play an important role in supporting their client's emotional well-being.

Demographic and COVID-19-Related Factors Associated with Depressive and Anxiety Symptoms Among African American and Latina Women in a Midwestern State

PURPOSE

The COVID-19 pandemic exacerbated racial and ethnic disparities among Latina and African American (AA) women, including risk factors for depression and anxiety. This study sought to identify demographic- and pandemic-related factors associated with depressive and anxiety symptoms in adult AA and Latina women living in a Midwestern state.

METHODS

Data for this secondary analysis of 1037 AA and Latina women were collected in May 2020 and June/July 2020. Participants completed an online survey about their demographic characteristics, job changes due to COVID-19, general concern about COVID-19, concern about the effects COVID-19 on their mental health, and whether they prayed to cope with COVID-19. Linear regressions with bootstrapping were conducted to determine associations.

RESULTS

Latinas had significantly higher depressive and anxiety symptoms than AA women. Older age was a buffer against depressive and anxiety symptoms. Women who anticipated a reduction in work hours or job loss had significantly higher depressive and anxiety symptoms than those with no job changes. A reduction in work hours was also a risk for higher depressive symptoms. General and specific concerns about the impact of COVID-19 were positively associated with higher depressive and anxiety symptoms. Race/ethnicity moderated the effect of praying to cope with COVID-19 on depressive symptoms.

CONCLUSIONS

As the pandemic continues, mental health resources should be allocated to help AA and Latina women who experienced or anticipate reductions in paid hours and those concerned about its effects. Research is needed to identify how praying increased depressive symptoms in adult Latina women early in the pandemic.

Pregnancy-related COVID worry, depressive symptom severity, and mediation through sleep disturbance in a low-income, primarily Latinx population in California's Central valley

PURPOSE

This study (1) assessed the psychometric properties of a pregnancy-related COVID worry scale, (2) explored variations in pregnancy-related COVID worry over the course of the pandemic, and (3) examined associations between pregnancy-related COVID worry and depressive symptom severity, and evaluated sleep disturbance as a mediator.

METHODS

Data were drawn from an ongoing randomized trial comparing the effectiveness of two enhanced forms of prenatal care. The current analysis includes baseline pre-randomization data collected from participants who enrolled November 2020-November 2021 (n = 201). Participants were pregnant individuals with low income and primarily Latinx.

RESULTS

Our 7-item scale was valid and reliable for assessing pregnancy-related COVID worry. Pregnancy-related COVID worry did not vary significantly by any participant characteristic or pandemic stage. Pregnancy-related COVID worry was significantly associated with depressive symptom severity in multivariate analysis (p = .002). For each unit increase on the 10-point pregnancy-related COVID worry scale, the odds of mild-to-severe depression increased by 16% (odds ratio = 1.16, 95% confidence interval 1.02-1.32, p = .02), holding all other variables constant. Sleep disturbance mediated the pregnancy-related COVID worry-depressive symptom relationship (48% of the total effect mediated).

CONCLUSIONS

Worry about how COVID may impact their baby, birth, and postpartum experiences was associated with higher depressive symptom severity, partly through its effect on sleep. These findings suggest that interventions related to improving sleep quality among perinatal populations may reduce depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04154423, "Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) Study".

Trends in postpartum mental health care before and during COVID-19

OBJECTIVE

To assess the impact of COVID-19 on trends in postpartum mental health diagnoses and utilization of psychotherapy and prescription drug treatment.

DATA SOURCES

Data were obtained from a large, national health insurance claims database that tracks individuals longitudinally.

STUDY DESIGN

We used interrupted time series models to examine changes in trends of postpartum mental health diagnoses before and during the COVID-19 pandemic and t-tests to examine differences in treatment.

DATA EXTRACTION METHODS

We used billing codes to identify individuals who received mental health-related diagnoses and treatment in the first 90 days after a birth hospitalization. We excluded individuals diagnosed with schizophrenia or bipolar disorder and those with an unknown payer at delivery.

PRINCIPAL FINDINGS

Compared to the pre-pandemic period, the trend in new postpartum mental health diagnoses increased significantly in the post-COVID-19 period (0.06 percentage points [95%CI 0.01, 0.11]). Over 12 months, the percentage of new diagnoses was 5.0% greater relative to what would be expected in absence of COVID-19. The percentage of diagnosed individuals who did not receive treatment increased from 50.4% to 52.7% (p = 0.003).

CONCLUSIONS

Findings point to an urgent need to improve screening and treatment pathways for perinatal individuals in the wake of COVID-19.

Navigating Pregnancy and the Healthcare System during COVID-19: A Qualitative Study with Perinatal Women of Color

OBJECTIVE

To address health disparities in the perinatal period (i.e., during pregnancy and through one year after birth) by exploring the intersectional experiences of perinatal Black, Indigenous, and other People of Color (BIPOC) women during the COVID-19 pandemic. In this study, participants were asked if and how COVID-19 had impacted their experiences of receiving healthcare, whether they had faced any challenges during this time, how they had navigated these challenges, and what recommendations they had for improving perinatal healthcare.

METHODS

Between November 2021 and March 2022 our team conducted eight virtual focus groups comprising perinatal BIPOC women. A semi-structured interview protocol was used, and interviews were voice recorded and transcribed verbatim. The data were analyzed using reflexive thematic analysis.

RESULTS

Three major themes common in BIPOC perinatal healthcare experiences during COVID-19 were generated through engaging in reflexive thematic analysis: (1) an overwhelming lack of support from providers, (2) experiences of blame and shame, and (3) difficulties navigating institutional policies that were unclear or ever-changing during the COVID-19 pandemic. Recommendations from participants included greater empathic communication from providers in the face of uncertainty during COVID-19, greater access to information and guidance for caring for themselves and their babies, and an overall request for greater compassion while navigating an exciting and busy time.

RELEVANCE

These findings have implications for trauma-informed and inclusive perinatal care that can reduce the impacts of systemic inequalities for perinatal BIPOC women. This study offers a discussion of implications for future training for maternal health providers and implications for community-based programs.

Stress-related psychopathology during the COVID-19 pandemic

The COVID-19 pandemic has introduced widespread societal changes that have required ongoing adaptation. Unsurprisingly, stress-related psychopathology has increased during the pandemic, in both children and adults. We review these patterns through the lens of several leading conceptual models of the link between stress and psychopathology. Some of these models focus on characteristics of environmental stressors-including cumulative risk, specific stressor types, and stress sensitization approaches. Understanding the specific aspects of environmental stressors that are most likely to lead to psychopathology can shed light on who may be in most need of clinical intervention. Other models center on factors that can buffer against the onset of psychopathology following stress and the mechanisms through which stressors contribute to emergent psychopathology. These models highlight specific psychosocial processes that may be most usefully targeted by interventions to reduce stress-related psychopathology. We review evidence for each of these stress models in the context of other widescale community-level disruptions, like natural disasters and terrorist attacks, alongside emerging evidence for these stress pathways from the COVID-19 pandemic. We discuss clinical implications for developing interventions to reduce stress-related psychopathology during the pandemic, with a focus on brief, digital interventions that may be more accessible than traditional clinical services.