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Karestan C. Koenen Ph.D.
Karestan C. Koenen Ph.D.

Pregnant During a Pandemic?

Mental health of pregnant and postpartum women during COVID-19.

An estimated 116 million women will give birth during the COVID-19 pandemic. According to the Centers for Disease Control, pregnant women who develop COVID-19 may be more at risk of developing severe illness and adverse outcomes, such as stillbirth.

Pregistry, used with permission
Source: Pregistry, used with permission

The public health efforts necessary to contain COVID-19 and protect the health of pregnant women and their babies have transformed the very experience of pregnancy and giving birth. Physical distancing means canceled in-person new parent classes, virtual baby showers, and dramatic limitations on prenatal care.

Women face giving birth without a partner or loved one, restrictions on hospital recovery times, and questions about whether it's safe for parents and other family members to visit. We and others have noted that COVID-19 has created traumatic stress — a sense of threat combined with unpredictability and uncontrollability, which can overwhelm the ability to cope — that is toxic to mental health. Pregnant women may be especially impacted and vulnerable to mental health problems during this time.

My colleagues and I conducted a global survey on the mental health and wellbeing of pregnant and postpartum women during the COVID-19 pandemic. Our goal was to understand better what pregnant, and recently postpartum women were feeling during this time, what most concerned them, and what helped them cope. The study anonymously surveyed over 7,500 participants, over 10 days, across 68 countries. We included the option for women to write in their most pressing concerns. For example:

"I'm feeling depressed because of unemployment, financially, my family is struggling. It seems like this corona is gonna make our lives more difficult, I'm worrying about my upcoming baby; there are so many questions coming to my mind. I feel this is the end of the world!”

“I had preeclampsia. I think it would have been detected sooner if I wouldn’t have had to cancel a Dr appointment.”

“I am most scared for my children and the ability to care for my children. If I get it, I can no longer breastfeed or comfort my kids . . . If my newborn gets it, he will be alone and I don't know his chances of survival . . . the real issues that keep me up at night and keep me praying and scared and vigilant are health concerns and what it would mean if any of us got sick.“

We are analyzing the quantitative data now, but results thus far are staggering. Over 70% of women report clinically significant depression or anxiety, and over 40% screen positive for post-traumatic stress disorder (PTSD). These estimates are consistent with those found in smaller, national studies showing increased rates of depression, anxiety, and post-traumatic stress symptoms.

Most notable is how many more peripartum women seem to be suffering from mental health problems during COVID-19, as compared to pre-pandemic estimates. Global data before COVID-19 suggest that approximately 12% of women experience perinatal depression, and about 15% of pregnant women and 10% postpartum women meet the criteria for any anxiety disorder. There are fewer studies on PTSD; however, evidence suggests the prevalence of PTSD before and after birth is 3.3 and 4%, respectively, and 18% in high-risk samples.

Our understanding of COVID-19 remains limited, particularly in terms of risks to pregnant women and their babies. In contrast, we know a lot about the importance of maternal mental health for both women themselves and the next generation. Maternal depression has numerous adverse effects on offspring ranging, for example, from irregular fetal heart rate to behavioral problems and obesity in childhood, and even criminal behavior in adolescence.

Prenatal anxiety is correlated with physiological effects such as lower vagal activity, cognitive effects, including lower mental development scores as well as internalizing problems. Few studies assess PTSD during the perinatal period, but limited findings suggest an association with low birth weight and less breastfeeding.

When I read these women’s stories, I could not help but compare them to my experience of being pregnant and giving birth to my son, Lorcan, now 13. I had a very stressful, high-risk pregnancy, including hospitalization due to a partial placental abruption and a month of bed rest. During the pregnancy, doctors told me repeatedly I would likely lose the baby. Lorcan was delivered early, at 35 weeks gestation, by emergency cesarean section due to a placental abruption. So, like the women we surveyed, I experienced almost constant worry about my baby’s wellbeing.

However, the social support I received buffered my worry and anxiety. My husband sat by my side during the entire delivery. My sister waited outside; she was the first person after my husband to hold Lorcan. My friend Alisa came to the Brigham and Women’s Hospital, nudging me out of bed to push Lorcan in circles down the hallway, around the elevator bank, and back “come on, you can do it, one more time.”

Once I got home, my mother, having reserved a room in a nearby bed and breakfast, visited daily to cook. Because I was high risk, the City of Cambridge provided a visiting nurse who showed my husband and me how to do everything, including properly diaper my son. Despite our two PhDs, we had been baffled by the fact that he woke up repeatedly soaked. During maternity leave, various new mothers groups, such as those run by Jewish Children and Family Services at no cost to the participants, provided structure to my days, the social interaction I desperately craved, and helpful information for adjusting to my new role.

I know most of the supports that were my lifeline during my pregnancy and following my son's birth are currently unavailable. Experts recognize this fact and have called for a system-wide response to meet the mental health needs of pregnant women during COVID-19. However, systemic change takes time, and women are pregnant and giving birth now. So what can pregnant women do?

First, join a virtual community. While the virtual will never replace the actual, technology and social media enable connection during physical distancing. Platforms such as Pregistry offer the opportunity to share your experience with other women globally and obtain evidence-based answers to your questions on how to keep yourself and your baby healthy. You can also participate in research virtually, for example, through the International Registry of Coronavirus Exposure During Pregnancy.

Second, be proactive. Educate yourself about mental health during pregnancy. If you are suffering, talk to a professional or call a help-line (SAMHSA: 1-800-662-HELP (4357), Remember mental health symptoms are common during pregnancy and postpartum and can be effectively treated. Since pregnancy and giving birth are associated with so many changes — in sleep, appetite, and mood — it can be hard to know what is healthy versus problematic. If you are concerned, do not wait for the provider to ask you screening questions. Although many providers now screen for depression, many still do not, and women are only rarely screened for anxiety or post-traumatic stress symptoms.

Finally, ask for help. If COVID-19 has taught us anything, it is that health is not solely the individual's responsibility, but is reliant on community. Research suggests that helping others makes us feel happier. If you are pregnant or have recently given birth, make a list of concrete ways others can help you. For example, can a family member research support services in your area? Could neighbors cook meals no that you could put in your freezer for later? Can you arrange for friends to pick up and do your laundry after the baby is born? It can be hard to ask for help but remind yourself it's a win-win. You get the support you need, and you offer others the opportunity to feel better at the same time.

About the Author
Karestan C. Koenen Ph.D.

Karestan C. Koenen, Ph.D., is a clinical psychologist, epidemiologist, and author. She is Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health where she aims to reduce the population burden of mental disorders.

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