Factors affecting the mental health of pregnant women using UK maternity services during the COVID-19 pandemic: a qualitative interview study

Background People using maternity services in the United Kingdom (UK) have faced significant changes brought on by the COVID-19 pandemic and social distancing regulations. We focused on the experiences of pregnant women using UK maternity services during the pandemic and the impact of social distancing rules on their mental health and wellbeing. Methods We conducted 23 qualitative semi-structured interviews from June 2020 to August 2021, with women from across the UK who experienced a pregnancy during the pandemic. Nineteen participants in the study carried their pregnancy to term and four had experienced a miscarriage during the pandemic. Interviews took place remotely over video or telephone call, discussing topics such as mental health during pregnancy and use of UK maternity services. We used reflexive thematic analysis to analyse interview transcripts. Results We generated six higher order themes: [1] Some pregnancy discomforts alleviated by social distancing measures, [2] The importance of relationships that support coping and adjustment, [3] Missed pregnancy and parenthood experiences, [4] The mental health consequences of birth partner and visitor restrictions, [5] Maternity services under pressure, and [6] Lack of connection with staff. Many participants felt a sense of loss over a pregnancy experience that differed so remarkably to what they had expected because of the pandemic. Supportive relationships were important to help cope with pregnancy and pandemic-related changes; but feelings of isolation were compounded for some participants because opportunities to build social connections through face-to-face parent groups were unavailable. Participants also described feeling alone due to restrictions on their partners being present when accessing UK maternity services. Conclusions Our findings highlight some of the changes that may have affected pregnant women’s mental health during the COVID-19 pandemic. Reduced social support and being unable to have a partner or support person present during maternity service use were the greatest concerns reported by participants in this study. Absence of birth partners removed a protective buffer in times of uncertainty and distress. This suggests that the availability of a birth partner or support person must be prioritised wherever possible in times of pandemics to protect the mental health of people experiencing pregnancy and miscarriage. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04602-5.


Background
Pregnancy is a significant life stage tied to events that can affect mental health and wellbeing [1]. Relationship difficulties, [2] childcare responsibilities, [3] long-term health conditions, [4] financial hardship, [5] stressful life events, [6] and natural disasters, [7] can also contribute towards maternal mental ill health. Many women experience profound changes in their identity, self-concept, and sense of meaning during parenthood [8]. They may also experience complex emotions such as shame and guilt, [8] which makes the availability of appropriate support during this life stage so important. Up to 63% of new mothers are estimated to experience symptoms of depression after childbirth, [9] with 10-15% experiencing symptoms sufficient for a diagnosis of postnatal depression [10]. The health and wellbeing of mothers during pregnancy is a critical public health issue as this period can pave the way for long-term health outcomes for parents and their children [11].
When the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic in March 2020, [12] the UK government advised people who were pregnant to take extra caution to protect themselves from infection [13]. The National Health Service (NHS) also classified pregnant women as "clinically extremely vulnerable" to the effects of COVID-19, [14] and subsequently implemented a number of precautionary changes in maternity service provision [15]. The NHS is a UKbased healthcare system, which offers publicly funded care to people residing in the UK requiring maternity services; however, patients can also opt to use private healthcare services that are paid for via alternative means, if preferred. The biggest changes to NHS maternity care during the pandemic included appointment cancellations, two-metre social distancing during face-to-face appointments, birth partner restrictions, and limiting the number of visitors during intrapartum care [16]. Changes in maternity care service provision varied around the world in response to setting-specific policies and patient demand, [17] and it is important to thoroughly investigate the impact of these changes in each of these contexts so that people using maternity services are appropriately supported in the aftermath of the pandemic.
Experts warned early on that steps taken to reduce the risk of virus transmission from mothers with confirmed or suspected COVID-19 to their newborns may have indirect health consequences, [18] such as difficulties with lactation and reduced parent-child bonding [16,19]. Emerging research has found increases in depression, anxiety and loneliness amongst women in the perinatal period during the pandemic [20] and an experience of miscarriage may place people at potentially higher risk of these symptoms [21]. Health service changes due to the pandemic (such as missed appointments or cancelled services) have been found to be significantly associated with trauma symptoms, depression, anxiety and loneliness [22]. Karavadra et al. (2020) found many women were concerned about remote antenatal appointments, partner visiting restrictions, and rapidly changing rules that affect health service provision [23]. In a qualitative interview study that explored barriers to healthcare seeking, specifically among women during the first UK lockdown in March 2020, authors found that women delayed seeking care due to fears of COVID exposure, negative media reports, and influence of social contacts [24]. Basu et al. (2021) also found that people experiencing pregnancy had concerns with changes in delivery plans and about the risk of their newborn being diagnosed with COVID-19 [22].
While quantitative data suggests that there have been increases in psychological distress for people experiencing pregnancy during the pandemic, [22] limited qualitative evidence has been published on why women may have experienced a decline in their mental health during this time. One qualitative study identified increased feelings of isolation and difficulties accessing breast-feeding and parenting support [3]. However, this study focused specifically on the postpartum period and experiences of women who had given birth, either before or during the very early stages the pandemic. Furthermore, this did not include the views of women experiencing a miscarriage during the pandemic. In the current research, we aimed to learn more about changes across the COVID-19 pandemic that may have contributed to a decline in mental health and wellbeing amongst pregnant women. We did this by exploring how the pandemic has affected pregnant women's mental health, wellbeing, and subjective experiences.

Study design
The research forms part of a larger mixed methods research project, which commenced in March 2020, called the Covid Social Study (CSS) [25]. The project was designed to evaluate the social and mental health impact of the Covid-19 pandemic (https:// www. covid socia lstudy. org/). For this current study, we deployed a qualitative research design using semi-structured interviews to elicit the perspectives of 23 women using UK Keywords: Pregnancy, Maternal mental health, Social support, COVID-19 maternity services during the COVID-19 pandemic. We obtained ethical approval prior to undertaking the study from the University College London Ethics Committee (Project ID: 14895/005).

Recruitment
We recruited a convenience sample of participants by circulating advertisements through social media (i.e., Twitter), a study newsletter (reaching around 3000 people), and personal contacts. Interested people contacted the research team to register for the study. AM or AB responded with further information and a screening questionnaire. We did not record response rates. Everyone who registered their interest had the opportunity to ask questions before joining the study. Eligibility criteria included being 18 years or older, having experienced a pregnancy and accessed UK maternity services during the pandemic, and being able to speak English sufficiently to read and understand the study information and informed consent forms.
In considering our focus on a study population where demographic factors can have important implications for participant experiences, [26] we opted to use purposive sampling strategies during study recruitment, whereby we screened participants in attempt to ensure demographic diversity within the group. The factors of interest during study recruitment known to affect pregnancy outcomes included maternal age, education level, [27] and ethnicity [28][29][30]. In addition to this, given the potential mental health impact of miscarriage among people experiencing pregnancy, [31] we also invited participants to take part based on having experienced a pregnancy and using UK maternity services during the pandemic, rather than having given birth and carrying to term alone.

Procedure
Interviewers (authors AM, AB) were female, PhD-level, qualitative health researchers with training in conducting research with people experiencing mental health problems. Participants completed their interviews from June 2020 until August 2021 (three interviews were conducted in 2020, 18 were conducted from early to mid-2021, and two were conducted from mid to late 2021). We offered participants a remote, one-off interview via telephone or online video call. All interviews were conducted oneto-one between the participant and interviewer. Participants provided written informed consent before taking part and completed a demographics form. Interviews followed a topic guide (see Supplementary file) based on our research group's existing CSS work on the mental health impact of the pandemic [32,33]. We added several additional open-ended questions designed to elicit responses on pregnancy experiences during the pandemic, as well as the impact the pandemic on mental health, wellbeing, access to support and social lives (Table 1).

Data analysis
Audio files from participant interviews were transcribed verbatim by a third-party transcription service. AB and AM checked transcripts for accuracy and anonymity before importing into Nvivo version 12 [34]. AM led on data analysis, incorporating reflexive thematic analysis (RTA) techniques [35,36] informed by critical realist ontology, [37] whereby we focused on semantic descriptions presented in the text rather than possible underlying meanings [38]. First, AM and AB independently coded three transcripts and met to discuss issues of importance identified. This step was carried out to develop a more nuanced and contextualised approach for interpreting and coding the transcripts. Codes were grounded in the data rather than being based on a preexisting theory or structure. The lead author (AM) read all remaining transcripts and then coded these with a focus on concepts relevant to the research question, rather than line-by-line coding of all interview data [36]. AM generated themes and subthemes with input from co-authors (AB and DF). For additional feedback during the analysis stage, the preliminary findings were also presented to the CSS qualitative research team, a group of researchers who have used RTA to analyse previous work on the mental health impact of the pandemic among specific groups [39][40][41]. We have selected illustrative quotes to demonstrate each subtheme; several have been shortened for clarity with full length and supporting quotes presented in Supplementary file 2. 2. Have your experiences of pregnancy/becoming a new mum during the pandemic had any impact on your mental health/wellbeing? 3. What has been the impact on any other services or groups you would have otherwise used? (e.g. NCT or support groups for pregnant women) 4. Did you have any specific worries about your pregnancy because of the pandemic?

Participant characteristics
We recruited 23 participants who experienced a pregnancy and used UK maternity services during the COVID-19 pandemic ( Table 2). Six participants said they used some form of private health services during the pandemic, including antenatal classes, prenatal testing, and pregnancy scans. Most participants described themselves as married and living with their partner. All participants identified as female. Sixty-five percent of participants were first-time parents. Four participants in total had experienced miscarriage during the pandemic, one of whom later gave birth to their first child in the second year of the pandemic. Sixty-one percent of participants identified as White British. Eight participants had a diagnosed pre-existing mental health condition, including premenstrual dysphoric disorder, depression, and anxiety. Two participants were experiencing post-natal depression and anxiety at the time of their interview.
Three participants had a pre-existing physical health condition, including a mobility condition, skin condition, and polycystic ovarian syndrome.

Thematic analysis
We generated six themes during the analysis about the mental health impact of pandemic-related experiences among pregnant women in the UK ( Table 3). Some of the emotions reported by participants corresponded to their experiences during pregnancy or postpartum specifically, and others spanned across all stages of pregnancy and parenthood. No experiences were universal, and we have attempted to capture these nuances within the following discussion of themes and subthemes.

Some pregnancy discomfort alleviated by social distancing measures
Most participants described some benefits during their pregnancy and parenthood that were associated with social distancing restrictions arising from the COVID-19 pandemic.
Avoidance of unwelcome attention from others Social isolation measures meant some participants were able to experience changes in their body during pregnancy without the unwanted gaze, touch, or commentary of other people. One participant described feeling uncomfortable during a previous pregnancy when people touched her stomach. The requirement to physically distance from other people meant no one touched her without her expressed permission. Social distancing regulations also meant that participants could avoid uncomfortable social encounters with others: "It's been nice not to have unsolicited visits, so that's one pro of it." At other times, participants were able to avoid unwelcome discussions about the early stages of their pregnancy, and rather, initiate these conversations at their own pace when they felt comfortable.
" … especially when you're not telling people that you're pregnant, to be able to just do that and never have to tell someone I wasn't drinking because I didn't see anyone, so that was great. " P5, aged [30][31][32][33][34], no children, with experience of miscarriage during pandemic

Importance of relationships that support coping and adjustment
Having supportive interactions with social contacts was described as having a pronounced impact on the mental health and wellbeing of participants in the study, and the absence of support contributed to further feelings of loneliness and isolation during the pandemic.
More time to build a connection as a family Lockdown restrictions meant that participants were able to spend more time with their partners and children that they may not have previously had the opportunity due to short parental leave allowances. The introduction of the "support bubble" system in the UK was described as a "lifeline" that made "a huge difference" to the mental health of those who needed the support of close friends and family members.

Missed pregnancy and parenthood experiences
Although participants reported benefits from some elements of the pandemic restrictions, such as being able to work from home with a supportive partner, there were also downsides to social distancing restrictions that participants said they found challenging. Many of these issues were more likely to be salient for first-time mothers.
Grief for a missed pregnancy experience Many participants who were first-time parents said they had looked forward to pregnancy rituals like baby showers or shopping for new items for their baby. They described disappointment that they missed these experiences, which were seen as rites of passage, due to shop closures and stay-at-home orders.

Mental health consequences of birth partner and visitor restrictions
Being unable to use maternity services with a partner was unsettling or stressful for most participants in the study. The impact of a partner's absence was described as one of the most salient points of their pandemic experience, as meaningful moments were lost and decision-making made more difficult.
Upset about partners being excluded from healthcare interactions A majority of participants reported that their partners were unable to accompany them to some or all hospital appointments and described this at times as "stressful", "difficult" and "traumatising". This was especially so for participants in the late stages of pregnancy or experiencing miscarriage. The absence of a partner in times of distress meant that some participants missed moral support and sources of reassurance. Consequently, several participants said they paid for private care (for services such as a pregnancy scan) or changed their birth plan to an elective c-section, in order to be able to have their partners present with them.

"I was really scared I'd be there for days on my own in pain without my husband, or that it would suddenly happen really quickly and he wouldn't be there, and he'd miss the birth of the baby. So it was quite a major factor in me deciding to ask for a C-section. " P9, aged 35-40, 1 st baby
The presence of birth partners on the postnatal ward was described as particularly important because they provided additional advocacy support and facilitated helpseeking at times when participants felt overwhelmed, exhausted, or distressed on the wards.

Lack of connection with staff
The subject of connection was discussed in relation to trust, touch, and support from staff, almost interchangeably by some of the participants in the study. These factors were described as important because this seemed to influence their level of satisfaction with care received.
Communication difficulties Participants reported some communication difficulties with staff during their interactions with maternity services. Several participants said they found it difficult to communicate with healthcare staff whilst wearing personal protective equipment (PPE) during appointments.
"That was really weird, and just going in with masks and seeing the doctors and the nurses through masks, that was all really weird. I'm quite a social person and I chat, it just made it all a lot more difficult. " P13, aged 35-40, 1 st baby Some participants felt that they did not receive the same quality of maternity service care during the pandemic compared to pre-pandemic times. This was a concern as some participants felt elements of their care might be missed due to remote consultations, particularly for those having their first child and uncertain of what to ask for, or unsure what was considered "normal. " "And I know that, normally, the health visitors would see you once a month … that is something that I really felt was quite a worry for me, especially in the beginning, because my son was premature and I was concerned about his weight and concerned about just lots of things developmentally. And I think just having a phone call about that was quite concerning. " P15, aged 30-34, 1 st baby Many found it difficult to "build a relationship" and gain "reassurance" from midwives and consultants over the phone. Participants with pre-existing mental health concerns, pregnancy-related anxiety, and experiences of miscarriage and pregnancy complications were more likely to say the lack of face-to-face care was a source of concern.
"The pregnancy didn '

Discussion
Since the start of the COVID-19 pandemic, some of the social distancing restrictions implemented in maternity services have now been critiqued for lacking evidence [42] and conflicting with human rights, [43] such as the separation of parents and new-borns. In this study, we explored how social distancing restrictions affected the mental health and wellbeing of women experiencing a pregnancy and accessing UK maternity services during the COVID-19 pandemic. This avenue of enquiry is essential for helping to improve policy responses regarding maternity care for future pandemics and emergencies. Aligned with existing research, the participants in our study shared concerns about reduced social contact and support, [3,44] as well as feelings of loneliness and isolation throughout their pregnancy, [45,46] all of which were exacerbated by the pandemic and associated restrictions. Isolation was experienced by participants in our study at multiple points along the antenatal care pathway. This included having continual remote consultations with pre-and postnatal care staff, being unable to see the same members of staff during their pregnancy, staff not being able to provide physical hands-on care after the birth and being unable to have birth partners present during service use. At the start of the pandemic, experts recommended precautions to reduce the risk of COVID exposure during antenatal visits, including offering women with uncomplicated pregnancy remote appointments [16]. While remote healthcare appointments may have increased access to healthcare among some groups during the pandemic, offering appointments remotely in the future is not likely to be a preference reported by all, particularly for those with serious health concerns [47]. Qualitative research interviews conducted in Canada suggest that women may prefer virtual postnatal care because it helps to regulate their family routine, reduce stress and save on expenses associated with travel to consultations [48]. However, for participants in our study experiencing a first pregnancy, pregnancy complications or a preexisting health condition, compulsory remote care was a source of great concern, leading to feelings of uncertainty and increased stress. Participants in our research described the psychosocial impact of restricted interactions with maternity care staff because of the pandemic, including staff being prevented from delivering "hands-on" care around their new-born babies. When significant practice changes such as these are implemented as they have been during the COVID-19 pandemic, [42] midwives and other maternity care professionals could be at risk of moral injury from having to uphold changes in care that conflict with their ethical values [49,50]. Additionally, participants in this study described feeling a lack of connection between themselves and their midwives due to social distancing requirements, which is important because this can prevent feelings of mutual trust and empowerment [51]. For participants in our study with high-risk pregnancies who may have been more vulnerable to isolation, fear, and grief, [52] relationships with health professionals were reported to be especially important. Factors such as lack of trust and continuity of care have been reported by women prior to the COVID-19 pandemic when using UK maternity services [53], but our findings highlight how these feelings were exacerbated by COVID-related restrictions. This included mandatory use of PPE, remote appointments, limitations to physical care, and staff shortages. Participants in our study described the various ways in which their social ties were cut due to social distancing restrictions and pandemic-related cancellations in parent groups and community services. These restrictions and cancellations compounded feelings of loneliness and isolation and ultimately mental health and wellbeing. Taken together with existing research, [54,55] these findings highlight the importance of accessibility to peer support groups for parents in times of pandemics. Introduction of the "support bubble" system whereby one household could form a support network with one other household [56] was a key change in social policy that brought about noticeable differences for participants struggling with isolation, miscarriage, new motherhood, childcare demands, and adverse mental health. For other groups beyond the current study, including domestic abuse survivors [57] and parents with young children, [58] many have also gained important sources of social support resulting from this policy. However, announcing the support bubble system to people earlier could have helped to mitigate some of the difficulties reported in this study.
Social distancing regulations have been emotionally challenging for many different groups within the general population [59,60], and participants in our study reported aspects of their social distancing experience during the pandemic that threatened their mental health and wellbeing. However, there were pandemic-related changes that were also helpful and meaningful. For those in the early stages of pregnancy, being required to stay at home helped them to feel safe from the virus and better able to manage their pregnancy symptoms. It is notable that some participants reported having to take less time off due to being able to work and manage their symptoms better from home, suggesting that more flexible policies on working from home during pregnancy could reduce sick days amongst pregnant people in the future. The women in our study said that having partners at home at the same time during their pregnancy also supported feelings of wellbeing by increasing access to practical and emotional support. A consistently reported finding is the strengthening of families [3] and relationships [46] under lockdown restrictions, but we found this connection also helped families make decisions about their future and feel more stable in times of great uncertainty during the pandemic.

Strengths and limitations
Owing to in-depth qualitative interviewing methods and a data collection period that spanned three national lockdowns, we were able to present a wide range of detailed experiences throughout the various stages of the COVID-19 pandemic in the UK. We used recruitment strategies to ensure variability of experiences within our group of participants, to increase the likelihood of the transferability of our findings to other settings [61]. We spoke with participants who had high risk and low risk pregnancies, and varying caring responsibilities during the pandemic, which allowed us to focus on some of these nuanced differences within the group during our study. Remote interview methods meant that people from across the UK could take part in the study; however, those without access to the internet may have been inadvertently excluded from taking part. Although we attempted to sample a wide range of demographic characteristics to explore the impact of these factors on experiences of pregnancy during the pandemic, our sample was restricted to married women, who were highly educated, in fulltime employment and aged mostly over 30, with some suspected but no confirmed COVID-19 diagnosis. Consequently, we were unable to "compare and contrast" the cases presented here as we might have been able to, had the sample been more demographically diverse [62]. Characteristics such as gender identity [63], marital status, age, ethnicity and socioeconomic group [64] can compound experiences of isolation and marginalisation in pregnancy, and warrant additional focus. We recommend future researchers explore the impact of pandemic-related changes among women who experience multiple forms of marginalisation, as these communities were disproportionately impacted by COVID-19 policy responses [65].

Conclusions
Our findings highlight aspects of care that must be taken into consideration in pandemics, emergencies or disasterrelated situations, in order to protect the mental health of people experiencing pregnancy and miscarriage. Some service adaptations during the pandemic have been critiqued for being overly cautious, with more nuanced approaches to antenatal care needed in the future [15]. Specifically, availability of a birth partner or support person must be permitted where possible, as these restrictions brought about the most distress and uncertainty for women in our study. Further, support bubbles not just post-birth but during pregnancy should be explored as a priority to provide adequate support with mental health, physical symptoms tied to early pregnancy, and highrisk pregnancies. Pregnant women in this study said they experienced a loss of social support and access to parent groups during the COVID-19 pandemic, which had a detrimental impact on their mental health and wellbeing, so more development of online or socially distanced support groups could help to address this issue in the future. The pandemic also placed additional pressures on the delivery of maternity services and many participants reported dissatisfaction with aspects of standard care that were exacerbated by social distancing restrictions. Further work is needed to explore the experiences of maternity staff during the COVID-19 pandemic, to identify what further support they feel is needed for delivery of maternity services in the future, as we move beyond the pandemic.