The purpose of this study was to understand the experiences of pregnant and postpartum women during the COVID-19 pandemic in an upper Midwest cohort. Specific themes that arose in our population included heightened uncertainty around medical care and pandemic-related changes, social isolation, and negative mental health impacts. However, a minority of respondents found moments of positivity in the pandemic, including more time and flexibility for activities like self-care or family bonding, a slower pace of life, and gratitude for their circumstances despite the surrounding chaos and uncertainty. Much of the initial literature around COVID-19 and the perinatal period focused on triage and the provision of medical care, but more recently published data have shed light on how the COVID-19 pandemic influenced other aspects of care that are important to our patients.
To our knowledge, Kinser et al. have been the only group to report qualitative data from pregnant and postpartum women using the COPE-IS survey . They surveyed this population in April–June 2020 at the height of the initial shutdown in an urban Southeastern US health system. Their qualitative analysis similarly revealed significant fear, anxiety, and mental health difficulties from the pandemic, though they reported more concerns over supply shortages, unemployment, and health insurance than we found in our population. These differing responses may reflect the stage of the pandemic during which the survey was distributed. However, both populations expressed fears of illness and death from COVID-19 – not only for themselves but also for loved ones. Both populations reported restricted social support during all stages of pregnancy and the postpartum period as well as sadness over the loss of an otherwise “normal” pregnancy experience. Interestingly, in Kinser and colleagues’ population, the majority of respondents reported gratitude for a change in perspective, including more time with family, opportunities for self-care, and a slower pace of life, whereas in our population, such feelings were reported by a minority of women.
Others have also reported qualitative data about the impact of COVID-19 on prenatal care using different survey instruments or via semi-structured interviews [29,30,31,32]. Javid et al. identified similar structural changes in healthcare and behavioral changes to reduce disease transmission (e.g. virtual visits and absence of support people, respectively) that led to emotional responses of increased fear, anxiety, and feeling unsupported. Others reported similar levels of both generalized uncertainty around the pandemic and perinatal care and more specific concerns related to the effects of viral infection on their own health and their children, feelings of missing out on a more traditional pregnancy experience, and challenges from limited family and medical care support [30,31,32].
Our data, in conjunction with the reports from other cohorts, suggest that during the COVID-19 pandemic, pregnant women in the United States felt reduced levels of support during their pregnancy as they navigated the changes to pregnancy care and delivery during a pandemic. However, additional data are needed from certain subpopulations, including single women, urban populations, and regions hit hardest by the pandemic, to gain a comprehensive picture of the similarities or differences based on population-level factors.
Sources of uncertainty
Many women experience feelings of uncertainty during pregnancy in non-pandemic circumstances . Our results suggest that the onset of COVID-19 resulted in two inter-related sources of increased uncertainty experienced by pregnant and recently pregnant women during this time. The first was the constant shifting of policies enacted by healthcare systems to adjust to the changing state of the pandemic. These policies included alternative models for prenatal care and various infection prevention measures for patients and staff. Within our own health system, our policies on visitation, masking, and admission testing changed from week to week based on government recommendations, risk of community spread, and site-specific factors.
The second, related source of uncertainty was the sudden onset of the pandemic and the rapidly shifting knowledge about infectivity, mode of transmission, morbidity, and effective prevention strategies. In particular, data on COVID-19 infection in pregnant women, infants, and children lagged significantly behind other demographic groups. One of the earliest reports describing the effects of COVID-19 on pregnant women was not released until mid-June 2020–3 months after the WHO declaration – and much of the data for neonates and infants was not reported until Summer 2021 [34,35,36]. This left pregnant women without the knowledge to make informed decisions about their care and prevention strategies, likely adding to their distress.
Prior to COVID-19, women have said that some of the inherent uncertainty of pregnancy fades with each successive pregnancy, but in our cohort, feelings of uncertainty did not appear mediated by parous status, with several respondents reporting that the pandemic birth experience was more stressful than their previous delivery experiences . In a state of unprecedented uncertainty, the healthcare system enacted policies to reduce disease transmission and enhance the safety of prenatal and delivery care in a fluid environment; unfortunately, many in our population found these policies frustrating and disruptive during a pivotal life experience. Stress exposure in pregnancy and the postpartum period, however, are known risk factors for poor maternal mental health and adverse health outcomes in children [18,19,20, 22, 38,39,40,41,42]. While important to acknowledge the role that new and shifting policies played in heightening uncertainty, we also recognize these changes were enacted by healthcare institutions out of the utmost concern for patient health and safety. A recent study of OBGYN providers during the COVID-19 pandemic showed they were also experiencing significant frustration and anxiety with changing policies . As healthcare systems respond to new SARS-Cov-2 variants of concern, they should integrate the knowledge gained from this dataset, and others, into their policymaking decisions to mitigate the stress experienced by pregnant and postpartum women. Improved communication of policy changes and evidence supporting such changes may promote transparency and mitigate feelings of uncertainty around pregnancy care and the delivery experience.
Though many women found these policies restrictive or burdensome, some women reported an improved pregnancy and delivery experience. These respondents appreciated the flexibility offered by telehealth, although some expressed concern that pregnancy and postpartum complications would be missed without a physical exam. Other pandemic surveys also demonstrated that both patients and prenatal care providers found virtual prenatal care to be feasible and satisfactory, although patients reported a strong preference for in-person appointments if given the choice [44, 45]. Since 2014, our health system has researched and implemented a reduced-frequency prenatal care model enhanced with remote home monitoring devices and nursing support . As such, many of our healthcare teams quickly adapted to this model, which may have contributed to some of the positive experiences seen in our respondents. Some serendipitous improvements could serve as launch changes to current perinatal care patterns, with future research looking at not just maternal and fetal health outcomes but also psychosocial considerations.
Loss of support and mental health
An additional source of considerable stress was the impact of changing policies on society more generally, including limitations on groups and social interaction, closures of schools and childcare centers, and reduced employment. The basal stress that accompanies pregnancy, birth, and caring for a newborn was layered onto the societal impact felt by everyone.
Perceptions of limited social support also affected this population. Pregnancy and the postpartum period carry a known risk of increased mental health concerns, and previous studies have demonstrated that social support is a protective factor against developing postpartum depression [20, 40]. Traditional avenues for assistance or respite care, such as older grandparents, family members, or friends, were limited due to social distancing and the increased COVID-19 risk among older populations . Those at even higher risk for isolation include single parents or others with limited support networks prior to the pandemic. Many respondents described additional responsibilities when daycare centers and schools closed indefinitely, juggling distance learning and care of a newborn alongside responsibilities at home and in the workplace. A qualitative interview study of young parents from the United Kingdom similarly pointed to limited social support as well as economic instability as key pandemic stressors that negatively influenced mental health in a population already at-risk for mental health concerns .
A minority of respondents felt pandemic changes had a positive effect on their mental well-being. Infection mitigation plans produced an environment where families could have more time at home, with fewer parents leaving the house for work and children for school or daycare, and fewer social obligations, which is supported by other qualitative findings on postpartum experiences during the COVID-19 pandemic . Some expressed relief in not having to entertain visitors during the postpartum period. Though some thrived in a newfound environment of self-care, others found less margin for respite or time alone, which has been associated with increased depressive symptoms during the postpartum period . Very few mentioned adopting new behaviors to protect their mental health, such as decreased use of social media or limiting news consumption.
A systematic review by Harville et al. demonstrated that exposure to disasters (e.g. terrorist attack, earthquake) increases risk for mental health issues for pregnant and postpartum women, and these data provide qualitative accounts that support their findings . Increased support of pregnant and postpartum women should be prioritized in times of need or social unrest given that isolation is a known risk factor for adverse maternal-fetal outcomes, including preterm birth and low birth weight [48, 49]. Further, postpartum depression also increases risk for maternal risk factors like substance abuse, suicidal ideation, and poor physical or mental health, or that ultimately impacts infant development . While beyond the scope of this study, maternal mental and physical health are also important for childhood development . This further highlights the importance of ensuring robust support for women and children during the perinatal period as well as long-term medical and psychosocial care for any children born during the pandemic period who may be impacted by heightened maternal stress and adverse mental and physical health.
Strengths and limitations
Strengths of this study include a large sample size for a qualitative dataset and detailed responses to the open-ended survey items, reflecting a variety of experiences. This survey was administered in Spring 2021 after medical knowledge and response to the COVID-19 pandemic was more solidified, with widely available testing and vaccines released to adults in the general public, so our results may not reflect the entire pandemic experience. The temporal distance from birth and prenatal care for women who delivered earlier in the pandemic may lead to recall bias. The low survey response rate (19%) is also a limitation; while respondent experiences are believed to be representative of this population, non-response bias may also be a factor. Generalizability of these findings is limited because of the regional nature of pandemic surges and varying local responses, including hospital policy changes, and limited racial/ethnic diversity. Though representative of the survey catchment area, the study findings do not capture the experiences of patients of color who are known to be at higher risk for poor maternal and fetal outcomes and mental health problems and who may experience disproportionate burdens of the pandemic. As the survey was delivered by email only, populations with limited or no internet access and those with limited English proficiency were not represented. Lastly, we distributed this survey over a year after COVID-19 had been declared a pandemic, which may have allowed time for reflection and influenced their ability to report positive pandemic-related changes that may have initially been reported negatively. Pandemic fatigue may have resulted in more negative responses. Additional research is needed to understand how pregnant and postpartum women are facing evolving challenges from the COVID-19 pandemic, such as how pregnant and breastfeeding women approach vaccination for themselves and their children, navigating daycare and school reopening or playdates with the continued risk of COVID-19 transmission, and how these women interact with the healthcare system after the designation of COVID-19 as a pandemic is removed. Further, because the COPE-IS survey was designed for pregnant and postpartum women, fathers were not included in this survey, but understanding how the COVID-19 pandemic impacted fathers or partners, including restrictions on support persons in labor and delivery, is another avenue for further research.