Depression,Anxiety,Resilience,and Coping: The Experience of Pregnant and New Mothers During the First Few Months of the COVID-19 Pandemic

Abstract

Background:

It is well-documented that the mental health of pregnant and postpartum women is essential for maternal, child, and family well-being. Of major public health concern is the perinatal mental health impacts that may occur during the ongoing coronavirus disease 2019 (COVID-19) pandemic. It is essential to explore the symptom experience and predictors of mental health status, including the relationship between media use and mental health.

Materials and Methods:

The purpose of this study is to evaluate the experiences of pregnant and postpartum women (n = 524) in the United States in the early phase of the COVID-19 pandemic. This cross-sectional online observational study collected psychosocial quantitative and qualitative survey data in adult pregnant and postpartum (up to 6 months postdelivery) women in April–June 2020.

Results:

Multivariable linear regression models were used to evaluate predictors of depressive symptoms, anxiety, and post-traumatic stress disorder. The most common predictors were job insecurity, family concerns, eating comfort foods, resilience/adaptability score, sleep, and use of social and news media. Qualitative themes centered on pervasive uncertainty and anxiety; grief about losses; gratitude for shifting priorities; and use of self-care methods including changing media use.

Conclusions:

This study provides information to identify risk for anxiety, depression, and PTSD symptoms in perinatal women during acute public health situations. Women with family and job concerns and low resilience/adaptability scores seem to be at high risk of psychological sequelae. Although use of social media is thought to improve social connectedness, our results indicate that increased media consumption is related to increased anxiety symptoms.

Introduction

The novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-novel coronavirus-2 (SARS-CoV-2), has rapidly affected mortality and morbidity across the world to pandemic proportions. A major public health concern is the mental health impacts that may occur due to prolonged uncertainty and acute stress during the pandemic. Recent reports from the Centers for Disease Control and Prevention suggest that symptoms of anxiety and depression have increased during the spring months of 2020 in the United States, compared with a similar time period in the prior year.¹ In particular, the impact of the COVID-19 pandemic on pregnant and postpartum women is of great interest not only for the health of these women but also the wellness of their children. Anxiety about the impact of the virus on pregnancy and infant outcomes abounds, particularly given data to suggest that pregnant women infected with COVID-19 might have greater risk of need for mechanical ventilation and may be at increased risk of preterm birth and other adverse outcomes.^2,3

Previous studies suggest that acute and chronic mental health problems during pregnancy can affect maternal/child attachment and other maternal/child health sequelae.⁴ Preliminary studies suggest that, during the pandemic, pregnant and postpartum women have experienced high rates of depressive symptoms and anxiety, accompanied by feelings of loneliness, stress related to uncertainty and lack of social support, and concerns about accuracy of information.^5,6 It is essential to conduct research on maternal mental health during pregnancy and postpartum given findings in the extant literature about the correlation of acute stress, anxiety, and depressive symptoms with poor maternal/child health outcomes (e.g., poor maternal health behaviors, suicide, intrauterine growth restriction, preterm birth, impaired breastfeeding, altered infant temperament and social/emotional development, adult-onset chronic illness in the child) and economic burden to the individual and society (e.g., medical costs, comorbidities).^7

–10

To contribute to the state of the science in this field, it is essential to understand the experiences of pregnant and postpartum women during the early phases of the COVID-19 pandemic in the United States. As such, the overall goal of this observational study is to examine the impact of COVID-19 on experiences of pregnant and new mothers and to set the stage for future longitudinal maternal/child health evaluations. In particular, we explore predictors of mental health status (depressive symptoms, anxiety, post-traumatic stress disorder symptoms) in pregnant and postpartum women in spring 2020, as related to demographics, economic, and psychosocial factors (e.g., resilience and coping). Furthermore, given the recent awareness of the risks related to an overabundance of information that may or may not be accurate (“infodemic”),¹¹ we explore the relationship between hours spent on pandemic-related content and mental health status in this population. Finally, these findings are further explained with findings from a description of themes arising from qualitative data elicited from participants. A thorough understanding of predictors of mental health status during this pandemic may contribute to the development of mental distress mitigation measures and may help clinicians identify women at greatest risk to implement effective prevention strategies.

Materials and Methods

Study design

Ethical approval for this study was obtained from the Virginia Commonwealth Institutional Review Board (IRB approval number: HM20019176). This cross-sectional observational study evaluated psychosocial quantitative and qualitative survey data collected in adult pregnant and postpartum (up to 6 months postdelivery) women in April–June 2020 in the United States; this was the time of initial shutdown for many states in the United States. and thus captures the acute reactions to the pandemic. There was no in-person contact for any aspects of recruitment, enrollment, or study visits. Upon IRB approval, women were recruited through multiple methods: social media posts; email listservs; emails, phone calls, and text messages to obstetric patients of an urban hospital system that has a large diverse patient population (n = 2435); and word of mouth from providers or other individuals in the community. Interested individuals were directed to click a link leading them directly to the survey landing page on an electronic capture system (REDCap¹² hosted on servers at VCU); during the informed consent process, individuals received an electronic information sheet about the study and the opportunity to opt-in to a study registry. If women expressed interest in the study, they were provided with a brief summary of the study through the study-specific REDCap space. Informed consent was obtained electronically at the time of enrollment. Completion of the survey questions was completely voluntary. At the end of the survey, participants were provided the opportunity to opt-in to provide their contact information to participate in a random drawing for a $100 gift card.

Measures

The study survey included several study-specific items as well as items from standardized questionnaires.

Mental health status

The Brief Symptom Inventory-18 (BSI) is a standardized questionnaire that measures psychological symptoms¹³ and has been widely used in a variety of populations and settings, including studies related to COVID-19 and to pregnancy. The suicidality item was omitted from this survey. Standardized subscales were calculated to measure depressive symptoms (five items) and anxiety (six items) by summing the five depressive-specific items and the six anxiety-specific items, and dividing by the number of questions answered. The BSI asks participants to indicate how much discomfort each problem has caused them during the past two weeks on a 5-point Likert-type scale (1 = not at all; 5 = extremely), through which higher scores indicate higher levels of depressive or anxiety symptoms; for example, items on the anxiety scale include “nervousness or shakiness inside,” “feeling tense or keyed up,” and similar.⁹ Reliability for the total scale was good (Cronbach's alpha = 0.891, 95% CI = [0.877–0.905]), as was the reliability for the depression subscale (Cronbach's alpha = 0.844, 95% CI = [0.822–0.864]) and the anxiety subscale (Cronbach's alpha = 0.833, 95% CI = [0.810–0.854]). A subset of questions from the post-traumatic stress disorder (PTSD) checklist for DSM-5 (PCL-5) was used to measure symptoms of PTSD; this measure asks respondents “in the past seven days, how often were you distressed by” feelings or experiences such as “feeling jumpy or easily startled,” “having difficulty concentrating,” and similar.^14,15 The subset of items was chosen to decrease participant burden, avoid redundancy with other items in the survey, and represent each DSM-5 criterion for PTSD covered in the original PCL-5 (criterion B-E); the questions from the PCL-5 asked participants to rate their symptoms on a Likert-like scale of 1–5 through which 1 = not at all; 5 = extremely) (of note, typically the PCL-5 is scored on a 0–4 scale, yet this study reports findings based upon a 1–5 scale), through which a higher score indicates higher levels of PTSD symptoms. The total PTSD score was calculated by summing the 10 items. The reliability for this scale was good (Cronbach's alpha = 0.837, 95% CI = [0.815–0.858]). Finally, the abbreviated Connor-Davidson Resilience Scale (CD-RISC 2) was used in which participants indicate the ability to “bounce back” (resilience) and “to adapt when changes occur” (adaptability) on two items scored with a 0–4 Likert-like scale (0 = not true at all; 4 = true nearly all of the time); scores are summed to create a total score.¹⁶ In previous studies in the United States, the mean CD-RISC 2 score was 6.91 in a general population, 5.12 in a group with depression, 4.96 in a group with generalized anxiety disorder, and 4.70 in a group with PTSD.^16,17 In this study, the reliability of this two-item scale was acceptable (Cronbach's alpha = 0.676, 95% CI = [0.615–0.727]).

COVID-specific items

The rest of the survey questions were study-specific items and items from the Coronavirus Perinatal Experiences Impact Survey (COPE-IS). Study-specific questions measured location in the United States and time spent on COVID-19-related media content. The COPE-IS is a new set of questions developed as a collaborative effort of scientists and clinicians, including authors of this article and others, with the intent to understand experiences of new and pregnant mothers during the COVID-19 pandemic.¹⁸ It has not been psychometrically tested at this time. COPE-IS items measure concepts such as demographics (age, race/ethnicity, income, gestational week if pregnant/postpartum week if postpartum), perinatal care disruptions, change in sleep, experience of COVID-19 symptoms, concerns about family, concerns about employment stressors, concerns about reduced access to care and resources, distress about medical care changes, restriction of activities, and coping activities. For example, with regard to concerns about family, participants were asked to indicate level of concerns about six issues potentially facing their family in the future: reduced access to food, medicine/hygiene supplies, baby supplies, mental health care, general health care, and access to positive social interactions; participants scored each item on a 1–4 scale (1 = not of concern; 4 = highly distressing). A sum score was created for total concerns (range 6–24), with a higher score indicating a higher level of family concerns. The reliability for this scale was good (Cronbach's alpha = 0.826, 95% CI = [0.802–0.849]).

Qualitative data

Participants were provided with an opportunity to comment on their general experiences with the COVID-19 pandemic through open-ended prompts such as: “people are affected by this pandemic in many ways; please share any of your personal experiences or ways in which your life has been changed” and “if you were to give advice to other pregnant or new moms during a public health crisis like the COVID-19 outbreak, what would it be?” Approximately 323 women completed these qualitative components of the survey.

Analysis

Continuous variables were summarized, unless otherwise indicated, using mean (STD) and minimum/maximum values. In some cases, continuous variables were summarized using mean (STD) and median with minimum/maximum values. Categorical variables were summarized using frequency (N) and percent (%) for the categories. Pearson correlations were utilized to assess the association between depressive symptoms, anxiety, and PTSD symptoms with the job insecurity score, the family concerns score, the CD-RISC 2 score, and COVID content time (hours). Multivariable linear regression models were constructed for depressive symptoms, anxiety, and PTSD as follows: variables were broken up into five domains, and for each of the domains all variables were entered into an initial model and then a backward elimination procedure was used and variables were dropped from the model based on their p-values; the backward elimination procedure stopped when all variables remaining in the model had p-values <0.05. Once a final model was arrived at for each of the domains, all significant domain variables were entered into an initial final model. Once again, a backward elimination procedure was utilized to remove variables from the final model based upon their p-values and the elimination procedure stopped when all remaining variables were significant at the 0.05 significance level. The five domains and the variables examined were as follows: (1) demographics (age, education, marital status, number of children in the household, number of adults in the household, race, family income, and currently pregnant), (2) COVID-specific status at data collection (mandatory quarantine, voluntary quarantine (two types), local government stay-in orders, local government and/or employer stay-at-home orders, no restrictions, and collection period), (3) economic factors and COVID-related content (job insecurity score, family concerns score, and COVID-related time in hours), (4) resilience and adaptability (CD-RISC 2), and (5) coping strategies (all those listed in Table 2 excluding low response items, e.g., use of tobacco, marijuana, CBD, new prescription drugs, over-the-counter sleep aids, talking to health and mental health providers). All quantitative analyses were done using SAS, version 9.4. A qualitative descriptive approach was used to analyze the qualitative comments from participants.¹⁹ Coding was conducted by one author manually, in which phrases related to each other, by content or context, were grouped into categories; these were then organized for subsequent examination as themes. Two authors independent of the initial coder reviewed the qualitative data and the themes. In cases of disagreement with the initial coding, the group engaged in discussion to come to consensus about the most appropriate themes. For confirmability and to enhance rigor, an audit trail was maintained about all decisions regarding coding and themes and direct quotes to illustrate themes were identified.^20,21

Table 2.

Mental Health Symptoms, Psychosocial Factors, Economic Factors, and Coping Strategies

Mental health symptoms	Mean (Std)
	[median; min, max]
	unless otherwise indicated
Global score (Brief Symptom Inventory [BSI])	1.59 (0.53) [1; 1, 4]
Depression (BSI subscale)	1.76 (0.76) [2; 1, 5]
Anxiety (BSI subscale)	1.67 (0.68) [2; 1, 5]
PTSD symptoms (Checklist for DSM-5)	1.61 (0.61) [1; 1, 4]
Psychosocial factors
Resilience and adaptability (Connor-Davidson Resilience Scale [CD-RISC 2])	6.15 (1.28) [6; 1, 8]
Distress about experienced changes to birth and postpartum care	3.66 (1.80) [4; 1, 7]
Distress about possible future changes to health care	5.00 (1.47) [5; 1, 7]
Overall change in stress since COVID-19	2.09 (0.65) [2; 1, 5]
Overall level of stress related to COVID-19	4.47 (1.41) [5; 1, 7]
Change in sleep [N (%)]
Worsened significantly	39 (7%)
Worsened moderately	154 (29%)
No change	310 (59%)
Improved moderately or significantly	20 (4%)
Hours spent on COVID-related content—all sources	3.37 (2.98) [Min = 0, Max = 20]
Economic and family factors	Mean (Std) [Min, Max]
Job insecurity score (Range 0–28)	4.68 (2.94) [Min = 0, Max = 16]
Family concern score (Range 6–24)	13.13 (4.09) [Min = 6, Max = 24]
Reported coping strategies (participants could select more than one)	N (%)
Getting a good night's sleep	232 (44%)
Meditation/mindfulness practice	110 (21%)
Talking with friends/family	441 (84%)
Engaging more in family activities	134 (26%)
Talking to people who are pregnant/parenting	166 (32%)
Increased screen time	242 (46%)
Increased time on social media	250 (48%)
Decreased time on social media	71 (14%)
Increased time following the news	105 (20%)
Decreased time following the news	182 (35%)
Eating comfort foods	221 (42%)
Eating healthier	86 (16%)
Increased reading time	159 (30%)
Exercising	187 (36%)
Helping others	92 (18%)
Drinking alcohol	50 (10%)
Low response items (items summed for brevity):
Use of tobacco, marijuana, CBD, prescription drugs, Sleep	29 (5%)
Aids talking to health or mental health providers	61 (12%)

PTSD, post-traumatic stress disorder.

Results

The characteristics of the study participants are summarized in Table 1. Of the 524 women who completed all of the survey items, the majority responded during the month of April 2020 (83%; n = 435) and were currently pregnant at the time (58%; n = 306). On average, the women were ∼33 years old (M = 32.6, SD = 4.52) and the majority self-identified as white (83%), partnered or married (94%), with a household income between $30,000–50,000 (45%), and had at least a college education or higher (82%). Almost all of the participants reported some kind of restrictions related to COVID-19, such as voluntary quarantine due to fear of exposure (54%) and local government orders to stay at home (87%). Very few participants reported mandatory quarantine due to confirmed or suspected cases in their family or friends (n = 11; 2%). The majority of participants (n = 469; 90%) reported living on the east coast of the United States. Of the 639 individuals who responded to some part of the baseline survey, respondents reported they heard about the study via social media (n = 249; 39%), email (n = 203; 32%), phone call (n = 82; 13%), text message (n = 4), and word of mouth (n = 69; 11%).

Table 1.

Description of the Sample Population (N = 524)

	N (%) unless
	indicated otherwise
Demographics
Age [Mean (Std)]	32.60 (4.52) [Min = 18, Max = 48]
Education
High school/GED or less	26 (5%)
Trade school/apprenticeship	11 (2%)
Partial college	35 (7%)
Associate degree	21 (4%)
Bachelor degree	173 (33%)
Graduate degree	256 (49%)
Marital status
Single	26 (5%)
Partnered/married	490 (94%)
Divorced/separated	3 (1%)
Other	3 (1%)
Number in household [Mean(STD)]
Children	1.33 (1.24) [Min = 0, Max = 8]
Adults	2.11 (0.53) [Min = 1, Max = 5]
Total	3.44 (1.46) [Min = 1, Max = 12]
Race
Black or African American	42 (8%)
Native American/Alaskan Native	1 (0%)
Asian	14 (3%)
Hispanic/Latin	11 (2%)
White	433 (83%)
Other/decline to answer	8 (2%)
More than one race/ethnicity	14 (3%)
Household income
< $30,000	80 (16%)
$30,001–$50,000	231 (45%)
$50,000–$80,000	145 (28%)
>$80,000	65 (12%)
First pregnancy	96 (39%)
Pregnant at time of survey	306 (58%)
Postpartum at time of survey	218 (42%)
COVID-specific status at data collection
COVID restrictions (more than one may apply)
Mandated quarantine—confirmed or suspected case	11 (2%)
Voluntary quarantine—confirmed or suspected case	26 (5%)
Voluntary quarantine—fear of exposure	285 (54%)
Stay-in order by local government	456 (87%)
Local government and/or employer stay at home order	187 (36%)
No restrictions	8 (2%)
Collection period
March 2020	1 (0%)
April 2020—first half	259 (49%)
April 2020—second half	176 (34%)
May 2020—first half	51 (10%)
May 2020—second half	32 (6%)
June 2020	5 (1%)

Quantitative results

Current symptoms and relevant psychosocial, family, and economic factors and self-reported coping strategies are summarized in Table 2. Because responses were similar between pregnant and postpartum women, all participants remained together in the quantitative analyses. Table 3 demonstrates correlations between scores of depressive symptoms, anxiety, and PTSD with each other and with self-reported job insecurity, family concerns, time spent on COVID-related content, and the resilience/adaptability score on CD-RISC 2. All three symptoms (depression, anxiety, and PTSD) are statistically, significantly, and highly positively correlated, with the correlation between anxiety and PTSD being especially notable (r = 0.8269). Higher scores reflecting distress regarding job insecurity (4.67, range 0–28) were correlated with higher depressive, anxiety, and PTSD symptom scores. Higher mean scores of distress about family health and well-being (4.09; range 6–24) were moderately correlated with higher depressive, anxiety, and PTSD symptom scores. The average number of hours spent per day on COVID-related content was 3.37 (2.98), and there was a trend such that more time spent on media content was related to anxiety symptoms. Higher resilience/adaptability scores on the CD-RISC 2 were associated with lower symptom scores on the depression, anxiety, and PTSD scales.

Table 3.

Mental Health Score and COVID-Related Concerns Correlations

	Anxiety	PTSD	Job insecurity score	Family concerns score	COVID content time (HRS)	Resilience and adaptability score (CD-RISC 2)
Depression
Correlation (r)	0.6922	0.6985	0.1489	0.4037	0.0352	−0.3208
p-value	<0.0001	<0.0001	0.0006	<0.0001	0.4224	<0.0001
Anxiety
Correlation (r)		0.8269	0.1473	0.3898	0.0852	−0.2998
p-value		<0.0001	0.0007	<0.0001	0.0516	<0.0001
PTSD
Correlation (r)			0.1965	0.4199	0.0286	−0.3371
p-value			<0.0001	<0.0001	0.5137	<0.0001

As depicted in Table 4, we arrived at multivariable models using linear regression to determine predictors of depressive and anxiety symptoms on the BSI subscale and PTSD symptoms on the PCL-5. Higher levels of the following factors predicted higher levels of depressive symptoms: family income, voluntarily choosing to quarantine due to fear of COVID-19 exposure, job insecurity score, family concerns, eating comfort foods, and social media use. Higher levels of resilience and getting a good night's sleep as a coping strategy were protective factors against depressive symptoms. This model for depressive symptoms arose with an adjusted R ² value of 0.2683. The multivariable linear regression model to determine predictors of anxiety symptoms on the BSI subscale that arose had an adjusted R ² value of 0.2406. Higher levels of the following factors predicted higher levels of anxiety: education level, family concerns score, eating comfort foods, and helping others. Higher levels of resilience (CD-RISC 2 score), getting a good night's sleep, and decreasing time watching the news were protective factors against anxiety symptoms. Finally, as shown in Table 4, the multivariable model derived from using linear regression to determine predictors of PTSD symptoms had an adjusted R ² value of 0.2956. Higher levels of the following factors predicted higher PTSD symptoms: scores of family concerns and job insecurity score, increased time on social media, helping others, and using a meditation/mindfulness practice. Higher resilience scores, getting a good night's sleep, and decreasing time watching the news were protective factors of PTSD symptoms.

Table 4.

Final Multivariable Linear Regression Models for Mental Health Symptom Scores

	Estimate	Standard Error	F-value	p-Value
Model for depressive symptom scores (BSI subscale)
Income			2.79	0.0400
<$30,000	0.3109	0.1135
$30,001−$50,000	0.1058	0.0939
$50,001−$80,000	0.1252	0.0986
>$80.000	0.0000	—
Voluntary Quarantine—fear of exposure	0.1812	0.0599	9.15	0.0026
Job insecurity score	0.0255	0.0104	6.00	0.0146
Family concerns score	0.0512	0.0076	45.48	<0.0001
Resilience and adaptability (CD-RISC 2)	−0.1074	0.0238	20.35	<0.0001
Getting a good night's sleep	−0.2123	0.0590	12.97	0.0003
Increased social media	0.1505	0.0610	6.09	0.0139
Eating comfort foods	0.1575	0.0614	6.58	0.0106
(Adjusted R² for Final Model = 0.2683)
Model for anxiety symptom scores (BSI subscale)
Education			3.71	0.0026
HS/GED or less	−0.1067	0.2158
Trade school/apprenticeship	0.0000	—
Partial college	0.0197	0.2063
Associate degree	0.5610	0.2252
Bachelor degree	0.2330	0.1852
Graduate degree	0.1753	0.1834
Family concerns score	0.0500	0.0068	54.04	<0.0001
Resilience and adaptability (CD-RISC 2)	−0.1183	0.0214	27.20	<0.0001
Getting a good night's sleep	−0.1254	0.0538	5.44	0.0201
Decreased time following the news	0.1308	0.0559	5.47	0.0197
Eating comfort foods	0.1327	0.0537	6.10	0.0139
Helping others	0.1828	0.0703	6.76	0.0096
(Adjusted R² for Final Model = 0.2426)
Model for PTSD symptom scores
Job insecurity score	0.0268	0.0079	11.55	0.0007
Family concerns score	0.0436	0.0059	55.23	<0.0001
Resilience and adaptability (CD-RISC 2)	−0.1136	0.0184	37.91	<0.0001
Getting a good night's sleep	−0.1087	0.0467	5.42	0.0203
Meditation/mindfulness practice	0.1490	0.0564	6.97	0.0085
Increased time on social media	0.1383	0.0457	9.15	0.0026
Decreased time following the news	0.1529	0.0483	10.02	0.0016
Helping others	0.1987	0.0604	10.81	0.0011
(Adjusted R² for Final Model = 0.2956)

Qualitative results

The themes that arose from the qualitative data are as follows: (1) pervasive fear and uncertainty with accompanying symptoms; (2) grief about various losses; (3) gratitude for shift in priorities; and (4) methods for self-care including changing relationship with technology. Representative quotes for the themes are provided in Figure 1.

FIG. 1.

Qualitative themes and representative quotes.

First, almost every participant expressed some degree of generalized fear and uncertainty accompanied by feelings of anxiety or depression regarding the pandemic situation. Participants reported worries about scarcities in food and supplies, uncertainties regarding employment and health insurance, reservations about hospital-based birth experiences, and concerns for the health of their family. Many participants reported fears about infection and illness and shared sadness about loved ones' deaths due to COVID-19. Participants noticed that they and/or their family members were more likely to feel irritable, anxious, and depressed than they were before the pandemic, or that preexisting symptoms were made worse from the uncertainty of the times.

Second, many participants expressed grief about loss, in a multitude of domains. Grief about changes in social support was pervasive, not only with regard to daily social interactions but also with respect to support from family and friends during labor, delivery, and the postpartum period. In addition, many participants were grieving the loss of not being able to experience and celebrate milestones, such as baby showers, having loved ones present for the birth of the child, and having the family members get to know the newborn. The phrase “I feel cheated/robbed” was repeated many times throughout the qualitative data. Participants also reported grieving the loss of readily accessible pregnancy- or postpartum-specific resources, such as prenatal yoga classes, childbirth classes, and doulas.

Third, despite the stress, fear, and losses, the majority of participants expressed gratitude for a shift in perspective and priorities that has occurred during the pandemic. Women reported having a new appreciation for quiet moments, family time, and a slower pace. Some expressed appreciation for stay-at-home requirements that allowed for more time together with their partner and more sharing of parenting responsibilities. While many women reported feeling overwhelmed with managing childcare and virtual school and work, simultaneously they expressed feeling grateful for learning about their inner strength to face difficult times. It should be noted, however, that many women reported partners being absent for various reasons, from military deployments to jobs requiring virus exposure, and/or that loss of daycare or school options for children added significant burden; these women did not express gratitude for any aspect of the pandemic situation.

Finally, many women offered thoughts about methods for self-care. One of the most pervasive comments was recognizing the need to avoid news and social media altogether. They suggested that news outlets and social media can trigger anxiety, particularly when one is “already tired and stressed with a newborn.” Many women suggested a need to change their relationship with technology, such that they could use social media or other modalities to maintain a connection with friends or family but it is important to avoid “sensational” content. Women repeatedly mentioned the importance of creating a “new normal” of support structures, such as reaching out to find other pregnant and postpartum women to talk with and to access mental health resources even before one notices symptoms. Some participants mentioned resistance to virtual technology at first, but that they had a growing realization of the need to embrace virtual visits to access necessary resources, such as mental health providers, obstetric/pediatric providers, lactation consultants, and similar. Many participants reported the importance of self-care activities because “you need to take care of yourself to be an effective caregiver.” Participants also used the phrase “let go of control” quite often, suggesting certain activities to help build resilience and adaptability such as taking time outside to get fresh air, engaging in exercise and eating well, trying meditation and mindfulness, using social media productively (for connection with friends/family), using prayer, and accepting help when it is offered.

Discussion

The aim of this observational study was to examine the impact of COVID-19 on experiences of pregnant and new mothers. In particular, this study evaluated predictors of anxiety, depressive symptoms, and PTSD symptoms in pregnant and postpartum women during the months of April–June 2020, in the acute phases of the COVID-19 pandemic. The findings from this study suggest that, in this sample of 524 pregnant and postpartum women in the United States, the most important relevant predictors of symptoms of depression, anxiety, and PTSD are related to family concerns, job concerns, resilience and adaptability scores, and the use of various coping strategies. Other than education level as related to anxiety symptoms, no other demographic characteristics were relevant predictors of mental health symptom severity. Although other studies about the COVID-19 pandemic are revealing similar findings about the mental health impact, our study is unique in that it reveals the role of factors such as resilience and adaptability for pregnant and postpartum women and it uses qualitative data to explain quantitative results.

The qualitative and quantitative findings in this study about anxiety, PTSD, and depressive symptoms are consistent with other literature being increasingly published about the COVID-19 pandemic. A recent report by Berthelot and colleagues (2020) about distress and psychiatric symptomatology in pregnant women during the pandemic suggests that women experience increasing levels of distress, depression, and anxiety compared with before the pandemic.²² In an online study conducted in Italy, Mappa and colleagues (2020) observed significant increases in maternal anxiety and a high prevalence of fear of abnormal perinatal outcomes during the spring of 2020.²³ In a study of a nonpregnant population experiencing quarantine during the COVID-19 pandemic, the majority of participants report experiencing at least one psychological distress symptom, such as fear, sleep disturbance, nervousness, irritation, feeling distant from people, memory difficulties, among others.²⁴ The qualitative reports from participants in our study suggest that fear and uncertainty were often accompanied by symptoms of anxiety and depression either in themselves or in their family members and children.

In this study, several coping strategies were associated with mental status: reports of eating comfort food were associated with increased anxiety and depressive symptoms, and reports of getting a good night's sleep were negatively associated with anxiety, depressive, and PTSD symptoms. In this sample, 42% of women reported eating comfort food as a coping strategy and this was found to be related to higher depressive and anxiety symptoms. During times of stress, individuals often preferentially consume highly palatable food—often referred to as “comfort foods”—to relieve negative emotions such as anxiety or sadness.²⁵ A recent study during COVID-19 and the subsequent lockdown in Italy found that 52% of respondents reported they were eating more “comfort foods” such as chocolate, ice-cream, desserts, and salty snacks.²⁶ Given the concern of weight gain and obesity in general, and the perinatal population specifically, this warrants further study. Getting a good night's sleep was also found to be related to mental health in this study. This is consistent with previous studies' findings that greater resilience to life challenges was significantly associated with better sleep quality in pregnant women²⁷ and that sleep disruptions are a key factor in mental disorders.²⁸ Of note, in other COVID-related studies, the use of exercise as a coping strategy was a protective factor for major psychological distress, and findings from several studies suggest that access to the outdoors and physical activity is associated with reduced stress in pregnant women.^5,6,24,29 However, despite that participants discussed this coping strategy in the qualitative data, exercise was not related to mental health status in the multivariate models.

In this study, psychological distress was a key aspect of the experience of pregnancy and being a new mother during the pandemic, which is similar to other studies about acutely stressful health crises or natural disasters. For example, in a study of 719 pregnant women in the United States during the Zika virus outbreak, pregnant women indicated that fear levels related to contracting the Zika virus were at levels similar to that of terrorist attacks, such as the September 11th attack in New York City.³⁰ Of clinical relevance is the amount of distress experienced by participants in this study because of the potential long-term impact on children who are in-utero during these times of acute stress. For example, in a study of women who were pregnant during Hurricane Sandy, the mothers with higher levels of depression plus exposure to the hurricane were more likely to have children with altered emotional regulation at six months.³¹ A review of the literature on floods as a major natural disaster reveals negative maternal/child health sequelae such as low birth weight, mental health disorders, PTSD, and stillbirth.³² Qualitative studies regarding natural disasters or health crises also corroborate these findings: pregnant women have expressed distress about body image, family planning, and prevention concerns, particularly regarding risks for birth defects regarding the Zika outbreak;³³ and concerns across a variety of domains in the aftermath of Hurricane Katrina, such as the health of the child and family, housing and finances, breastfeeding, mental health, and loss.³⁴ In the qualitative findings in our study, many women commented about the need to remain calm and engage in self-care, not only for their own wellness but also for the wellness of their child and family. It is important to note that a lifetime history of depression can be one of the most important predictors of future depressive episodes in the perinatal period³⁵; our study is limited in that we were unable to obtain a medical history from participants.

A key finding in this study was the relationship between self-identified resilience (i.e., resistance to distress following adverse life experiences) and severity of mental health symptoms. Resilience has been found to be a consistent protective factor in relation to a broad psychosocial outcome in the wake of diverse stressors and traumatic events.^36
–38 In the qualitative data from our study, many women identified methods for enhancing resilience and adaptability such as changing their relationship with technology (e.g., avoiding news outlets and social media and/or using technology to maintain support with friends, family members, and health care providers) and engaging in self-care activities (e.g., exercise, time outdoors, eating well, prayer). Although not specifically tested due to the cross-sectional nature of the study, the buffering hypothesis—that resilience will moderate the impact of a stressor on mental health—is a predominate theory used to explain findings in this area. Indeed, prior longitudinal studies have found that the impact of a new-onset stressor is mitigated among those with higher pretrauma resilience.³⁷ Using future waves of data collection the findings in the present study will be extended to test the buffering hypothesis in this population.

Both our quantitative and qualitative findings suggest that time spent watching COVID-19-related media content, either through news outlets or social media, can be related to mental health symptom severity. Women who spent more hours per day attending to COVID-19 information were more likely to experience anxiety symptoms. This finding is consistent with recent studies that suggest there is an “infodemic,” such that individuals are bombarded with so much information that it is unclear whether the information is reliable or helpful.¹¹ Excessive screen time is a concern for many clinicians and researchers, given previous findings that stress can be triggered by addiction to social media and by an overabundance of news.^39,40 A study of respondents in Canada and the United States revealed that the COVID-19 stress was related to increased use of Facebook, television, YouTube, and streaming services such as Netflix, and women were likely to identify social media as a coping tool.⁴¹ A study in Iraq reported a correlation between increased social media use and increased feelings of panic and/or anxiety, particularly when the social media information focused on COVID-19 infection rates.⁴² In a study of community-dwelling adults in China during the spring of 2020, almost a third of the population surveyed reported spending more than 2 hours per day on COVID-19 news via social media,⁴³ which is less than the amount of exposure in our study (mean hours per day = 3.3). The Chinese study found a correlation between excessive social media use and depressive symptoms, stress, and anxiety; however, time spent on COVID-19 news via television was not associated with depressive symptoms or anxiety.⁴³ In a random sample of 1000 individuals in the New York area who were exposed to Hurricane Sandy, stress levels were higher in those who used social media to obtain information about the hurricane, as opposed to those using “traditional” media (e.g., newspapers, radio, television); the researchers propose that social media may enhance anxiety for users because it creates “emotional contagion” when users perceive anxiety in other like-minded individuals.⁴⁴ Others have called this “packaging panic,” through which social media can amplify feelings of panic and anxiety.⁴⁵ On the contrary, social media has been touted as an important intervention for enhancing social support and potentially mitigating the mental health impact of quarantine and restricted activities. It should be noted that studies suggest that, particularly for women, online social networks may facilitate enhanced feelings of social connectedness during times of physical isolation, despite that social media simultaneously can increase feelings of stress.⁴¹ Participants in our study reported trying to change their relationship with technology to maintain a semblance of social support, such as using virtual modalities to connect with friends and family.

Limitations

Despite the relatively large sample size, this study has several important limitations. First, this is a cross-sectional assessment and does not measure medical or social history preceding the pandemic nor does it capture information about partner- or family member-perceived experiences with COVID-19. Rather this is an assessment of women in pregnancy and postpartum during the peak incidence of SARS-COV-19 in the United States. Generalizability of these findings is a limitation. Second, although attempts were made at enhancing racial/ethnic diversity by conducting targeted phone calls and messaging to diverse patient groups in the academic health system, the majority of participants were white and well-educated. This homogeneity of the population is unfortunate, given what is known about minority populations being particularly affected by COVID-19. In addition, women with less access to technology are unlikely to be represented in the sample, given that data collection occurred using an online data capture system. Third, the inability to know the exact locations of participants and the heterogeneity of the pandemic in different areas (e.g., women in urban areas versus rural areas may have had divergent experiences) introduces unknown error in the data. Finally, there was a very strong correlation between anxiety and PTSD symptoms, which could be interpreted by some as indicating that the survey items measured the same construct. However, the correlation is not at unity and the correlation suggests that those who react with distress to a situation will likely experience a multitude of symptoms that warrant close attention. In a recent systematic review of 19 studies about the impact of the COVID-19 pandemic on mental health in the general population, there were 12 studies focused on depressive symptoms and 11 on anxiety, yet only four studies measured symptoms of PTSD.⁴⁶ This suggests a gap in the literature and points to the importance of addressing the complexity of symptom experiences during this public health crisis. Future research should closely evaluate the symptom experience of anxiety and PTSD as the COVID-19 pandemic continues to unfold and to affect the global population, and our study contributes a unique perspective on these symptoms in pregnant and postpartum women.

Conclusions

Our study provides important information to help identify women at high risk of anxiety, depression, and PTSD symptoms during the COVID-19 pandemic. Pregnant women with family concerns, job concerns, and low resilience and adaptability scores seem to be at highest risk of psychological sequelae. By keying in on these factors, providers may be able to identify at-risk women to implement early psychological intervention to help mitigate these issues. By following this cohort of women moving forward, we hope to evaluate the long-term effects of this pandemic to further inform providers. Finally, although utilization of social media is thought to improve social connectedness, our results indicate that increased media consumption, particularly about sudden events such as the COVID-19 pandemic, relates to increased anxiety symptoms. Moving forward care must be taken to consider how social media can be used more effectively as a social support tool rather than an anxiety-contagion mechanism.

Footnotes

Acknowledgments

Hearty thanks to research assistant Nayab Mughal for her involvement in recruitment of participants for this study and to Sally Russell for her data management skills. Thanks also to research assistants Elsie Baker, Lilly Cai, and Madison Brown for their assistance in literature reviews and to Dr. Lisa Phipps for her guidance of these students.

Authorship

All authors have contributed substantially to this article according to ICJME guidelines.

Author Disclosure Statement

No competing financial interests exist. All authors having nothing to disclose with regard to competing interests, personal financial interests, funding, employment, or other competing interests.

Funding Information

This study was conducted with the support of the Virginia Commonwealth University School of Nursing Internal Grants Program and the Sarah P. Farrell grant. The use of REDCap was supported by the Clinical and Translational Science Award (CTSA), award No. UL1TR002649, from the National Center for Advancing Translational Sciences.

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