Decline in mental health during pregnancy throughout the COVID-19 lockdown period

Several researchers have reported significant stress accompanying the lockdown restriction imposed on large populations to hinder the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), during the first year of the coronavirus disease 2019 (COVID-19) pandemic. This was especially the case during the perinatal period, when many women require additional physical and emotional support.

Study: Mental health of pregnant women during the SARS-CoV-2 pandemic in France: evolution of self-perceived psychological state during the first lockdown, and anxiety frequency two months after the lockdown ended. Image Credit: Corpii/ShutterstockStudy: Mental health of pregnant women during the SARS-CoV-2 pandemic in France: evolution of self-perceived psychological state during the first lockdown, and anxiety frequency two months after the lockdown ended. Image Credit: Corpii/Shutterstock

A new preprint study posted to the medRxiv* server examined the changes in the mental state of pregnant women over the first COVID-19-related lockdown in France, and the persistence of anxiety-related symptoms over the two months following the end of the lockdown. This may help frame more appropriate interventions as required during future pandemics.

Introduction  

Earlier pathogenic coronavirus-caused severe respiratory disease outbreaks occurred in 2002 and 2013, respectively, called severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). These were found to be especially severe in pregnant women, causing acute respiratory distress syndrome at a higher incidence than in the non-pregnant population.

As a result of these experiences, an early recommendation was made during the ongoing COVID-19 pandemic that pregnant women should be at higher risk of more severe disease from the virus. This led to their being asked to isolate or remain secluded from interactions outside their household for longer periods than the general population.

However, many studies subsequently demonstrated that lockdowns during earlier outbreaks of infectious disease have been associated with spikes in anxiety, depression, mental distress and sleep disorders, some of which continue to manifest after the lockdown is removed.

A second source of distress is from the removal of social and emotional support systems, which is already an identified risk for mental ill-health during pregnancy and the peripartum period.

Thirdly, the known increase in risk for this subset of women put them at risk of feeling anxiety for their health and the baby they were carrying. The enforced isolation of lockdowns would only exacerbate this.

And finally, this could impact their overall health and that of their children, while also affecting normal infant-maternal bonding.

In fact, a number of recent papers have described such negative results of the pandemic itself, with pregnant women being reported to have higher levels of anxiety, depression, and hostility. The current preprint is based on the data gathered during the Covimater study.

The aims were to understand how women saw their mental state, before and during the first lockdown in France, from March to May 2020; and how frequent was anxiety and factors linked to symptoms of anxiety, at 2 months post-lockdown.

The researchers asked questions like: “Just before the lockdown, on a psychological level, how did you feel?”, “During the lockdown, on a psychological level, how did you feel?”, to understand how the woman felt her mental health had changed.

They also asked how a range of emotions, from relief, peace, frustration, and fear to despair, were experienced during the lockdown – more or less intensely than usual. And finally, they were assessed for anxiety symptoms at the second time point, using the Hospital Anxiety and Depression scale (HAD).

Analysis was done using demographic tabulated data, such as self-employed or managerial-level women, blue-collar or ordinary employees, and students or unemployed women; age and educational level, as well as financial level. The presence of children, professional workload, functioning of the healthcare system during the pandemic in the woman’s location, and social support as experienced by the woman were also analyzed.

Finally, the woman’s knowledge about SARS-CoV-2 spread, the presence of suspicious symptoms, and a history of family members with the disease were assessed. Her health status and the woman’s feeling of vulnerability to the virus were also asked about.

Other questions related to medical consultations during the first lockdown – cancellations or postponements of appointments by the doctor, talks with medical care providers about the pandemic and their pregnancy, having sleeping pill prescriptions for sleep disorders or mood aberrations during the pandemic, were other items that were included in the survey.

Findings

The mean participant age was 31 years, most had completed their high-school diploma or more, and a third were unemployed or students. A little over a third were employed in low jobs, and almost the same proportion was financially just scraping by. One in five was in financial distress.

About 45% said their location had experienced overwhelm by the healthcare system.  One in three said family or friends had a history of COVID-19, and less than a half had young children at home during the lockdown period. About a fifth said they had little or no support during the lockdown, while almost a third had undergone an atmosphere of violence or severe quarrels at this time.

Over half the women said their mental health had suffered during the lockdown, and one in five said their previously good psychological state had become poor. This was largely linked to the absence of social support, overwork, and uncertainty about how the virus spread and how it manifested.

Less than 10% of those whose mental health suffered during the lockdown had a psychiatric or psychologist to support them, though one in five desired such support but failed to obtain it. Three out of four women said they did not need this kind of help despite their deterioration in mental health.

About 60% of women said they felt more powerless, frustrated, and fearful during the lockdown than they normally would, with most women checking off 3/6 negative feelings related to this period.

About one in seven had anxiety symptoms, related to one or more pregnancy complications, increased body mass index (BMI), young children (<6 years) in the household, family or friends with suspected or confirmed COVID-19, and little social support during the lockdown. Women who tried to talk with their healthcare providers but failed were more likely to be anxious compared to those who succeeded. So were those who tried to obtain sleeping pills or antidepressants, compared to those who did not need such medication.

Implications

The findings of this study indicate that half of the women in the study sample experienced a deterioration of mental health during the first lockdown. A fifth of them said they went from having good mental health to ill-health, during this period. The research also identified several risk factors associated with such worsening, including poor support, overwork (as when small children are at home, along with a job), and inadequate knowledge of how the virus was transmitted and, therefore, of how this could be prevented.

This may account for the feelings of fear, powerlessness, and frustration reported by most women during this time. In addition, obesity, chronic illness, poor health and pregnancy complications are known factors for anxiety and decreased mental health in the peripartum period. At the same time, the well-publicized association of increased body mass with more severe COVID-19 may have impacted such women adversely.

Overall, a decline in mental wellbeing was significantly more frequent among pregnant women at 21%. Conversely, in the Coviprev study of women in the reproductive age group in the French general population at the same time, the incidence was <8%. This corroborates earlier studies during prior quarantines.

The persistence of anxiety symptoms was related to certain distinct factors, again related to those factors that precipitated a worsening of mental health. The actual incidence of such symptoms was, however, lower or comparable to that in other countries before the pandemic.

Our results for anxiety may reflect adaptation and habituation to Covid-19 health risks by pregnant women,” as “in women of childbearing age in the general population.”

In fact, CoviPrev showed a higher incidence of anxiety symptoms among reproductive-age women. The reasons for this are still unclear.

The benefits of properly informing pregnant women about the modes of spread of the virus in safeguarding their mental health has been shown in such studies, as well, and is confirmed in the current research. In addition, attention must be given to maintaining healthcare for pregnant women; giving them mental and social support; providing opportunities for them to ask healthcare providers about pregnancy-related questions and about their hospitalization for labor and delivery; and ensuring childcare for those who need it.

*Important notice

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.

Journal reference:
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.

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