The United Kingdom faced the brunt of the early phase of the coronavirus disease 2019 (COVID-19) pandemic, resulting in severe restrictions on personal interactions and supportive care during pregnancy, labor, and the postpartum period. This has adversely affected the perception of women and their families or support persons about their experience of pregnancy during the pandemic.
Study: Factors Affecting the Mental Health of Pregnant Women Using UK Maternity Services During The COVID-19 Pandemic: A Qualitative Interview Study. Image Credit: Natalia Deriabina / Shutterstock.com
A new study published on the preprint study medRxiv* reports the findings of a qualitative study of the determinants of the mental state of pregnant women during the pandemic within the U.K. maternity services.
“Reduced social support and being unable to have a partner or support person present during maternity service use were the greatest concerns reported by women in this study, as this absence removed a protective buffer in times of uncertainty and distress.”
Pregnancy is among one of the most important changes that occur in a woman’s life, affecting not just her physical state but also her mental health. During the pregnancy, many factors operate to produce the overall experience. This includes difficulties with significant people, the responsibilities of taking care of the baby, life stress, financial difficulties, and unforeseen natural events.
Mental changes occurring during this time include alterations in the sense of identity and of the meaning of life, as well as shame or guilt. Postnatal depression occurs in up to one in seven mothers, while almost two-thirds experience negative or low moods at this time.
The presence of these changes means that women require support from people near them during this period, especially since their long-term health and that of their families are dependent on the way they cope with this time.
In the U.K., many changes occurred in maternity services in order to shield pregnant women, who were considered high risk for COVID-19-related complications. This included replacing many in-person services such as outpatient appointments with virtual ones while enforcing social distancing of two meters during the appointments that did take place. Furthermore, most maternity services did not permit anyone but the patient to attend such appointments, restricted visitors during labor and the immediate postpartum period, and limited newborn babies to being handled largely by the mother alone to prevent viral transmission.
Early warnings of the adverse outcomes of such changes were not lacking, including difficulties with establishing breastfeeding and less bonding between mother and child. In fact, current research suggests these were largely correct, with mothers reporting increased depression and loneliness, especially if they were miscarrying or had a high-risk pregnancy.
These effects of the COVID-19 pandemic were linked to an inability to access needed care, which resulted in missed or canceled appointments, lack of continuity of care with frequent changes in the provider, and/or poor post-natal follow-up. Not being able to have husbands, mothers, midwives, or other social support people with them during these difficult periods was a source of grievance and emotional stress to many women.
The reasons for this are explored in the current study. This paper is among the few that examine the experience of women with respect to mental health over the whole of their pregnancy and post-partum, including those who miscarried at this time.
The researchers found six common themes during their interviews of 23 women, most of whom were married and living with their spouses. Over 60% were White British, and 15 had one child, four had two, but three were childless due to miscarriages during the pandemic. Eight women had been diagnosed with mental ill-health, including depression, anxiety, and premenstrual dysphoric disorder.
Some women reported that pregnancy-related discomfort was reduced by the restrictions since people did not know about the pregnancy and therefore did not constantly ask about the mother’s health. Also, not having to go out even for work or shopping reduced the need to cope with motion sickness, work routines, and tiredness and/or nausea, while conferring flexibility to work when they felt well.
Secondly, some reported that their family bonding improved, thereby helping them to cope better and adjust to the changes. Access to their immediate support group was very important in allowing women to have company and support while remaining safe. Parents’ groups were key to proper adjustments at this time, though several reported difficulties with the virtual meetings.
Thirdly, some women reported grief and sadness over not being able to share their experiences of pregnancy and new parenthood with others, particularly the first months after the baby was born.
The fourth area of concern was the anxiety and stress experienced about support partners not being able to attend appointments, be in the labor ward especially during childbirth, and especially at the time that important information is required to make decisions about the mode of delivery, for instance. The women reported a feeling of loss of support and advocacy without their support personnel nearby.
The women who participated in this study also felt that the process excluded the partner from any significant involvement with the pregnancy and childbirth. Rapidly changing COVID-19 norms left the patients unable to discern how much the staff was aware of current regulations.
Hospitals often appeared to be in chaos, perhaps because the staff was sick or the caseload was high. The effect on the patient was a reduced perception of support, increased worries that their care was inadequate, and simultaneously an induction of guilt about asking for help when things were obviously tight.
Another source of discontent was the inability to experience continuity of care with one doctor or midwife, for instance, especially with high-risk pregnancies. Patients were perturbed at having to repeatedly discuss their pregnancy issues and experiences of concern to each new provider.
Lastly, the no-touch policies often led to a sense of detachment or communication failure, especially with the mask on to obscure facial expressions. The difficulty in building and maintaining a relationship was mentioned, as well as missed health issues due to appointments being conducted only on the phone for several months.
Many changes in maternity healthcare occurred due to the pandemic, with accompanying adverse effects such as feelings of increased loneliness and isolation from social and medical support systems due to restrictions on in-person interactions. The current study looked at these phenomena from the viewpoint of the women affected.
The findings of the current study suggest that while remote consultations may have helped enhance healthcare access for some groups, many women prefer in-person care, especially if they have health issues of concern. This is not in agreement with all studies, with one paper from Canada, a larger country with a more far-flung population, indicating a preference for virtual care in order to cut down on time, expenses, and stress associated with hospital visits, while minimizing the resulting disruption of family routines.
Inability to connect with healthcare providers on a personal level hinders rapport-building, thus potentially leaving loopholes for mistrust and disempowerment. The failure to provide continuity of care is another characteristic of pandemic-related changes, which added to already existing problems in the U.K. healthcare system. The simultaneous cutback on social and family interactions exacerbated feelings of loneliness and isolation.
“Disrupted connection with staff alongside partner and visitor restrictions left [the women] feeling alone during childbirth and postnatal care.”
The introduction of the support bubble system was important in mitigating the issues of isolation, adverse pregnancy outcomes, the challenges of caring for young children, and depression/anxiety. This system, in which two households support each other, could have been introduced earlier to prevent the build-up of such stress, the authors remark. However, this system has since been extended to cover survivors of domestic abuse and all parents with young children.
Flexibility at work was a positive aspect of pandemic restrictions, as it allowed pregnancy-related symptoms to be managed more easily and reduced days off work among pregnant women. These restrictions also allowed for more support at home from partners, with greater family bonding and shared decision-making about the future.
“This suggests that the availability of a birth partner or support person must be prioritized wherever possible to protect the mental health of women experiencing pregnancy and miscarriage in times of pandemics. Support bubbles during pregnancy should be explored as a priority to provide adequate support with mental health, physical symptoms, and high-risk pregnancies.”
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.