By Nicole Cirino, MD, CST, IF
Reproductive Psychiatrist, Associate Professor of Psychiatry and OB/GYN, Oregon Health & Science University, Portland
Dr. Cirino reports no financial relationships relevant to this field of study.
The obstetrical effect of COVID-19 has received attention worldwide. However, data examining the psychological effect on women in the perinatal period still are emerging. Although there is little doubt that COVID-19 has increased depression and anxiety in many demographic groups, a small amount of existing literature, presented in this article, begins to give us some insight into the incidence, risk factors, and protective factors for mental illness in perinatal women during the COVID-19 pandemic. Prior to the onset of the pandemic, depression and anxiety affected one in seven women during the perinatal period and were associated with preterm delivery, maternal mortality by suicide, delays in cognitive and emotional development in offspring, poor maternal bonding, and an increase in incidence of chronic maternal depression. Prenatal psychological distress also has been consistently shown to be associated with poor developmental outcomes in offspring.1,2
Current published literature on the effect of COVID-19 on perinatal mental health is limited, particularly in U.S. populations. Published research captures populations in Qatar, the United Kingdom, Canada, China, and Ireland. Several factors are thought to be mediating increased anxiety and depression during the pandemic, in which pregnant women particularly are susceptible. These include the effect of physical and social isolation, the effect of decreased physical activity, the increase in financial insecurity, fear of infection in the individual and in one’s family, barriers to obtaining medical and mental health care, and the effect of limitations on schools, activities, and childcare.
Incidence and Risk Factors
Several groups have used a variety of methodologies to study the effect of the COVID-19 pandemic on perinatal mental health. A Canadian group surveyed 1,754 women prior to and during the COVID-19 pandemic, comparing rates of depression and anxiety in two cohorts. The data from the pre-COVID-19 pandemic exposure were collected early on, during the first two weeks of April 2020. After controlling for known risk factors for perinatal mental illness, including maternal age, gestational age, household income, education, and lifetime psychiatric disorders, the data showed a large effect size in the difference between the two cohorts. Results showed that 10.9% of the COVID-19 cohort had clinically significant levels of anxiety and depression, compared to only 6.0% of the pre-COVID-19 cohort (odds ratio = 1.94). Pregnant women assessed during the pandemic also reported more symptoms of post-traumatic stress disorder (PTSD) and dissociation than women from the pre-COVID-19 cohort. Risk factors for both cohorts included younger age, history of psychiatric illness, lower household income, and lower education. They concluded that pregnant women particularly would be likely to experience high levels of depression and anxiety symptoms during the COVID-19 pandemic, which may have a deleterious effect on mothers and fetuses, even in socioeconomically privileged women with low-risk pregnancies.1
Effati-Daryani et al performed a cross-sectional study of 205 pregnant women in Iran. Depression, stress, and anxiety symptoms were observed in 32.7%, 32.7%, and 43.9% of participants, respectively. Based on an adjusted general linear model, they found marital life satisfaction, lower levels of spousal education, and lower income were the most significant predictors of depression, anxiety, and stress for pregnant Iranian women during the COVID-19 pandemic.3
A cross-sectional survey of women accessing maternity services in Qatar during June and July 2020, also indicated a high prevalence of anxiety and depression (34.4% and 39.2%, respectively) compared to pre-pandemic rates. In this study, unlike others, the difference in rates during the pandemic was not affected by occupation, previous history of mental health problems, or pregnancy complications.4
A cross-sectional survey conducted at the University of Naples Federico II (Napoli, Italy) from March 15 to April 1, 2020, was aimed at assessing the psychological response of pregnant women during the COVID-19 epidemic. None of the enrolled women had a history of postpartum depression in a prior pregnancy or of psychiatric disorders. More than two-thirds of the women reported higher than normal anxiety. More than half of the respondents (53 of 100, 53%) rated the psychological effect as severe. Almost half of the women (46%) reported high anxiety regarding the vertical transmission of the disease. Women in the first trimester of pregnancy during the COVID-19 pandemic had higher anxiety and a more severe psychological effect than those in the second or third trimester of pregnancy as measured by the State-Trait Anxiety Inventory (STAI).5
Cameron and colleagues studied the effect of COVID-19 on Canadian mothers with children ages 0 to 8 years. They found that 41.5% of all mothers in self-reported validated screens (EPDS and CESD) met criteria for clinical depression. For mothers of children ages 0 to 18 months, depression was associated with previous mental health history, lower parental education, lower household income, and presence of employment loss. Thirty-six percent of these mothers scored above the clinical cut-off for anxiety. In this sample, only 21% of the mothers who had significant anxiety or depression accessed individual counseling in the past month.6 A single cross-sectional study with 859 respondents in China from Feb. 28 to March 12, 2020, showed a decrease in depression, anxiety, and stress rates in pregnant vs. nonpregnant women. Pregnant women during the COVID-19 pandemic reported lower rates of depression and anxiety (5.3% and 6.8% vs. 17.5% and 17.5% in the nonpregnant cohort).7
Effect of Positive COVID-19 Test
Kotabagi and colleagues attempted to clarify the course of depression and anxiety symptoms as well as the effect a positive COVID-19 test had on levels of distress. They studied two cohorts of pregnant women in the United Kingdom in March and April 2020, comparing one arm who tested positive for the illness with the other, who tested negative. Fourteen COVID-19-positive mothers were compared to a control group of 14 non-COVID pregnant women (average gestational age of 32.8 weeks). Scores were collected within one week of diagnosis and were followed weekly. Median General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scores did not differ statistically between arms, and both arms reached a maximum at the height of the pandemic deaths in the United Kingdom when “lockdown” rules were instituted, but they declined later as more information and national guidelines were released through government-run social media (the Royal Colleges of Obstetricians and Gynecologists and Midwives Guidelines). In this small study, the authors concluded that GAD-7 and PHQ-9 median scores were broadly low in both groups, even with a positive COVID-19 test, with a nadir in both groups following the release of national information. They also suggested that the sociodemographic influences of the pandemic affected pregnant women equally, irrespective of their COVID status. This article fails to define if positive COVID-19 cases were symptomatic.8
Effect of Activity Level
Davenport and colleagues studied not only the incidence of depression and anxiety during the pandemic but also looked at these rates in association with level of physical activity. Canadian perinatal women (58% pregnant and 42% within one year following delivery) were surveyed between April and May 2020. Of 900 eligible women, 64% reported reduced physical activity with the onset of quarantine. In this sample, 15% reported depressive symptoms (self-reported Edinburgh Postnatal Depression Scale [EDPS] above 13) prior to the pandemic, with a 40% positive screen for depression after the onset of COVID-19. Moderate to high anxiety was identified in 29% of women before the pandemic and in 72% of women during the pandemic (STAI-state score ≥ 40). Women engaging in at least 150 minutes of moderate intensity physical activity (meeting current guidelines) during the pandemic had lower scores for both anxiety and depression on the EPDS (median score 8 vs. 13, P < 0.001) and STAI (median 43 vs. 53, P < 0.001).2
In Ireland, Corbett and colleagues looked at the effect of COVID-19 on 71 second- and third-trimester pregnant women in March 2020. They studied maternal anxiety, particularly focused on health-related anxiety. They found that more than half of the subjects, most who did not have a previous history of health-related anxiety, experienced worry about their health often or all the time (50.6%). Pregnant women ranked their fears, with the highest being an older relative’s health (83%), followed by other children’s health (83.3%) and their unborn babies’ health (63.0%). Lastly, they worried about their own health (51.0%). When information was presented to these patients about COVID-19 and health outcomes at the end of the survey, 77% found this information extremely helpful.9
Published data examining the effect of the COVID-19 pandemic on perinatal mental health are sparse and have some conflicting results and several limitations. First, most of these studies occurred during the beginning of the pandemic, occurred outside the United States, and were self-reported questionnaires. Although several studies were able to identify possible risk factors, none of the studies looked at the efficacy of specific interventions, the course of symptoms across the pandemic, or the effect on obstetric outcomes or offspring outcomes. However, with the world now nearly nine months into the COVID-19 pandemic, we may be able to draw some preliminary conclusions to inform ways to improve care of the perinatal female during the pandemic.
Thus far, evidence does support the notion that psychological distress caused by factors related to the COVID-19 pandemic leads to increased rates of depression and anxiety disorders in perinatal patients. Risk factors may include a younger age, history of psychiatric illness, lower household income, lower education levels, and lower levels of marital satisfaction. Positive COVID-19 test status did not appear to increase risk in one small study. Anxiety symptoms also cluster in health-related anxiety as well as PTSD symptoms. Factors related to less severe symptoms include dissemination of health-related information, decline in COVID-19 cases, increased physical activity, and improved economic, marital, and parenting support.
Bertholet and colleagues suggested that obstetric providers can play a role in the mental health surveillance of pregnant women during the COVID-19 pandemic by “simply inquiring about specific distress or symptoms during prenatal care, or inquiring about the level of paternal support”; increasing “different forms of telehealth assistance to women with elevated psychological distress, such as toll-free helplines to answer the questions of pregnant women and online psychological support”; and disseminating information about psychological distress and relief of distress to all pregnant women.1 (See Table 1.)
- Berthelot N, Lemieux R, Garon-Bissonnette J, et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet Gynecol Scand 2020;99:848-855.
- Davenport MH, Meyer S, Meah VL, et al. Moms are not OK: COVID-19 and maternal mental health. Front Glob Womens Health 2020; June 19. doi: 10.3389/fgwh.2020.00001.
- Effati-Daryani F, Zarei S, Mohammadi A, et al. Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC Psychol 2020;8:99.
- Farrell T, Reagu S, Mohan S, et al. The impact of the COVID-19 pandemic on the perinatal mental health of women. J Perinat Med 2020; Sept. 25. doi: 10.1515/jpm-2020-0415. [Online ahead of print].
- Saccone G, Florio A, Aiello F, et al. Psychological impact of coronavirus disease 2019 in pregnant women. Am J Obstet Gynecol 2020;223:293-295.
- Cameron EE, Joyce KM, Delaquis CP, et al. Maternal psychological distress & mental health service use during the COVID-19 pandemic. J Affect Disord 2020;276:765-774.
- Zhou Y, Shi H, Liu Z, et al. The prevalence of psychiatric symptoms of pregnant and non-pregnant women during the COVID-19 epidemic. Transl Psychiatry 2020;10:319.
- Kotabagi P, Nauta M, Fortune L, Yoong W. COVID-19 positive mothers are not more anxious or depressed than non COVID pregnant women during the pandemic: A pilot case-control comparison. Eur J Obstet Gynecol Reprod Biol 2020;252:615-616.
- Corbett GA, Milne SJ, Hehir MP, et al. Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic. Eur J Obstet Gynecol Reprod Biol 2020;249:96-97.