Keywords COVID-19 pandemic - corona - pregnancy - postpartum - stress
Introduction
The global COVID-19 pandemic, which began in the winter of 2019/2020, represents a
long-lasting exceptional situation that affects the people involved on different levels.
In addition to
worrying about being infected with COVID-19 themselves and becoming seriously ill,
or having those close to them become ill, the measures ordered by the government also
changed the lives to
which people had become accustomed. Contact restrictions, in particular, led to serious
changes in many areas of life. These, for example, included restrictions in the professional
world, in
the education sector, religious practice, leisure activities, but also in the health
system [1 ]
[2 ]. Such changes can have long-term effects on people’s mental health [3 ]. Although some positive effects such as a
“deceleration of everyday life” have been reported [4 ], various studies have meanwhile shown that a large part of the population reacts
with increased stress and increased symptoms of depression and anxiety to the circumstances
of the COVID-19 pandemic [5 ]
[6 ]
[7 ].
Stress during pregnancy can have negative effects on the mother and thus also on the
mental and psychomotor development of the growing child [8 ]
[9 ]. Risk factors for increased stress during pregnancy include stressful negative life
events, lack of social
and/or financial support, depression, anxiety or worry and complications during pregnancy
[10 ]
[11 ]
[12 ]. If symptoms of depression and/or anxiety occur during the pre- and postnatal period,
these may not only
affect the mother but also the child in the long term. Furthermore, symptom-related
changes in maternal lifestyle and metabolism during and after pregnancy can have a
negative influence on the
fetal development and later on the postnatal development of the child [13 ]
[14 ]
[15 ]
[16 ]
[17 ]. Postnatal maternal anxiety and depression can also influence the mother’s behavior
towards the child or the mother-child interaction [18 ]
[19 ]
[20 ]
[21 ]
[22 ]. Therefore, the period of pregnancy as well as the postpartum period is a
sensitive time for the mother and the long-term development of the child.
Especially in the vulnerable period of pregnancy, birth and puerperium, changes that
occur due to the COVID-19 pandemic and the associated measures can trigger or even
intensify worries and
fears and thus increase the risk of developing prenatal and postnatal depression [23 ]
[24 ]. To date, studies published on pregnancy during the COVID-19 pandemic show that
anxiety symptoms in pregnant women generally appear to increase [5 ]. Stress symptoms, which may increase the risk of depressive symptoms or anxiety
symptoms, as well as pregnancy-specific anxiety occur more
frequently [25 ]. The increase in anxiety and depressive symptoms in pregnant women during the COVID-19
pandemic is a multinational trend
and is not limited to individual countries [24 ]
[26 ]
[27 ]
[28 ].
A detailed analysis of the experience and behavior of pregnant women and mothers in
the postpartum period during the COVID-19 pandemic is warranted. Differentiated recording
of worries and
limitations, but also of possible coping strategies and helpful support, offers the
opportunity to develop and implement interventions in time in order to reduce or avoid
negative consequences
for mothers and children. The COPE-IS (Coronavirus Peripartal — Impact Survey) questionnaire
was developed as part of the international COVGEN initiative (https://www.covgen.org ) to investigate the effects of the COVID-19 pandemic on the peripartum period and
has been translated into various languages [29 ].
In the present study, pregnant women and mothers in the postpartum period were interviewed
using the COPE-IS questionnaire. The evaluation focused on the subjective sense of
stress caused by
the COVID-19 pandemic. General level of stress, stress with regard to an own potential
disease and stress with regard to a potential disease in the close family or circle
of friends was
compared to the care situation as well as to pre-existing diseases.
Methods
Subjects
From the end of November 2020 to August 2021, a questionnaire-based cross-sectional
study assessed the impact of the COVID-19 pandemic on the mental health of pre- and
postpartum women. The
criteria for inclusion were pregnancy or childbirth since the official start of the
COVID-19 pandemic (11 March 2020), being of legal age and having German language skills.
Questionnaire
The German version of the COPE-IS (https://www.covgen.org) was used. The online version
of the questionnaire was promoted via posters and flyers, as well as via social media.
For inpatients
of the Department of Women’s Health at the University Hospital of Tübingen a hardcopy
version was used, as online access was not available for all patients during the inpatient
stay.
For pregnant women (Item #P1–Item #P14 and Item #20–Item #80) and postpartum women
(Item #1–Item #80), the questionnaire consists of a separate part and a common part
(see additional
materials S1 ). The items relate to the stress experience in connection with the COVID-19 pandemic
and to altered experiences during pregnancy and after birth. Demographic data, the
presence of other diseases and the availability of social support were also queried.
The study was approved by the Ethics Committee of the Faculty of Medicine of the University
of Tübingen
(586/2020BO1), and all study participants gave their written consent to the participation
and processing of their data.
The items “Overall level of stress related to the COVID-19 outbreak” (Item #58), “How
distressed are you about your own COVID-19-related symptoms or potential illness”
(Item #25) and “How
distressed are you about COVID-19-related symptoms or potential illness in friends
and family” (Item #26) were each measured on a seven-step scale from 1 (“No distress”)
to 7 (“Highly
distressed”) and described by the median (Mdn) and the interquartile range (IQR).
Also on a seven-step scale from 1 (“not supported”) to 7 (“very supported”), the extent
of support from the
social network (Item #41, #42) before as well as during the COVID-19 pandemic was
queried (i.e. at the time of the survey).
Statistics
The data were not normally distributed (Kolmogorov-Smirnov test) and were analyzed
by non-parametric tests (Kruskal-Wallis test, Mann-Whitney U test, Wilcoxon test).
SPSS Statistics
(version 27) was used for the statistical evaluation of the data. Results with a p-value
from 0 to < 0.05 were considered significant.
Results
Study subjects
A total of 503 subjects participated in the study. One hundred and seven women from
the online cohort and 7 women from the inpatient cohort were excluded because of incomplete
questionnaires. Since a total of 12 women reported the last delivery date before 01
March 2020, they were also excluded from the study ([Fig. 1 ]).
Fig. 1 Fig. Flow chart of the evaluated questionnaires. A total of 503 subjects participated
in the study (393 outpatients used the online version and 110 inpatients the paper-and-pencil
version of the questionnaire). One hundred and fourteen questionnaires were either
incomplete or contained an incomplete declaration of consent and 12 participants had
already given
birth before the official start of the corona pandemic (01 March 2020). This meant
that 377 women (274 outpatients and 103 inpatients) were included in the evaluation.
We were therefore able to evaluate questionnaires from 377 women. The online cohort
consisted of 156 pregnant and 118 postpartum women. The inpatient cohort consisted
of 103 postpartum
women at the Department of Women’s Health, University Hospital Tübingen ([Table 1 ]).
Table 1
Description of the study population.
Subjects
M = mean; n = number of subjects; SD = standard deviation.
* Inpatients were administered the paper-and-pencil version of the questionnaire.
** A positive COVID-19 test result or whether the patient was ill at the time of filling
in the questionnaire was not recorded.
Included subjects; n (%)
377 (100.0)
156 (41.4)
118 (31.3)
103 (27.3)
Age; M (SD)
32.09 (3.8)
Pregnancy; n (%)
211 (56.0)
166 (44.0)
Week of pregnancy; M (SD)
Week postpartum; M (SD)
27.1 (9.7)
10.4 (12.7)
Positive COVID-19 test**; n (%)
12 (3.2)
Annual household income; n (%)
8 (2.1)
10 (2.7)
37 (9.8)
37 (9.8)
51 (13.5)
70 (18.6)
68 (18.0)
47 (12.5)
12 (3.2)
37 (9.8)
Highest degree; n (%)
30 (8.0)
128 (34.0)
64 (17.0)
54 (14.3)
45 (11.9)
27 (7.2)
27 (7.2)
2 (0.4)
Subjective stress level due to the COVID-19 pandemic
Study participants reported an increased overall level of stress (Item #58; Mdn = 4;
IQR = 3) due to the COVID-19 pandemic ([Table 2 ]). In the
overall cohort, this value differed significantly from the “1” stress scale (1 = “no
stress”; p < 0.001; Wilcoxon test). Similarly, study participants reported both an
increased level of
stress with regard to their own COVID-19-related symptoms or a potential illness (Item
#25; Mdn = 3; IQR = 2), as well as an increased level of stress with regard to COVID-19-related
symptoms or a potential illness in friends and family (Item #26; Mdn = 4; IQR = 3)
([Fig. 2 ]). There was no significant difference between the
online and inpatient cohort for any of these three items.
Table 2
Stress level due to the COVID-19 pandemic.
Overall level of stress
Mdn (IQR)
Stress related to an own potential COVID-19 disease
Mdn (IQR)
Stress related to potential COVID-19 disease in friends and family
Mdn (IQR)
For outpatients before or after childbirth and for inpatients, the median of answers
1 (“no stress”) to 7 (or “extremely high stress”) is shown for items “Overall level
of stress
related to the COVID-19 outbreak” (Item #58), “How distressed are you about your own
COVID-19-related symptoms or potential illness” (Item #25) and “How distressed are
you about
COVID-19-related symptoms or potential illness in friends and family” (Item #26).
IQR = interquartile range; MDN = median; n = number of study participants
total; (n = 377)
4 (3)
3 (2)
4 (3)
Outpatient pregnant; (n = 156)
4 (2.75)
3 (2)
4 (2)
Outpatient postpartum; (n = 118)
4 (2.25)
4 (3)
4 (2)
Inpatient postpartum; (n = 103)
4 (3)
3 (2)
4 (3)
Fig. 2 Fig. Subjective stress level due to the COVID-19 pandemic. For outpatients before
or after childbirth and for inpatients, the distribution of answers 1 (“no distress”)
to 7 (“highly
distress”) is shown for items a “Overall level of stress related to the COVID-19 outbreak” (Item #58), b “How distressed are you about your own COVID-19-related symptoms or
potential illness” (Item #25) and c “How distressed are you about COVID-19-related symptoms or potential illness in friends
and family” (Item #26). The red line corresponds to the
respective median.
Pre-existing diseases
A total of 233 women (61.8%) reported the presence of pre-existing diseases in the
household. Of these, 93 women (24.7%) had a pre-existing disease of their own; for
140 women (37.1%)
diseases were present only in other members of the household. Options for pre-existing
diseases were respiratory problems, diabetes, lung disease, heart disease, liver disease,
cancer,
disease-related immunodeficiency and affective disorder (Item #62, Item #63). For
the qualities “How distressed are you about your own COVID-19-related symptoms or
potential illness”, (Item
#25; p = 0.003; Kruskal-Wallis H test) and “How distressed are you about COVID-19-related
symptoms or potential illness in friends and family” (Item #26; p = 0.022; Kruskal-Wallis
H test),
the stress level was significantly different in the groups “no pre-existing disease”,
“own pre-existing disease”, and “member of household with pre-existing disease”. In
the context of
post-hoc analyses, women who themselves had a pre-existing disease reported a significantly
increased stress level ([Table 3 ]) (Item #25:
p = 0.001; Item #26: p = 0.021). Particularly respondents with respiratory diseases
experienced significantly increased stress levels with regard to own COVID-19-related
symptoms or potential
illness (Item #25; p = 0.002; Mann-Whitney U test).
Table 3
Stress level in relation to pre-existing disease in the household.
Overall level of stress
Mdn (IQR)
Stress related to an own potential COVID-19 disease
Mdn (IQR)
Stress related to potential COVID-19 disease in family and friends
Mdn (IQR)
The median of responses 1 (“no distress”) to 7 (“highly distressed”) for items “Overall
level of stress related to the COVID-19 outbreak” (Item #58), “How distressed are
you about
your own COVID-19-related symptoms or potential illness” (Item # 25) and “How distressed
are you about COVID-19-related symptoms or potential illness in friends and family”
(Item
#26) is shown for subjects without own pre-existing diseases or diseases in the home
environment, for women who themselves had a pre-existing disease and for subjects
with
pre-existing diseases in the home environment. In the context of post-hoc analyses
(Dunn-Bonferroni), there was a significant difference compared to women who did not
themselves
have previous disease or diseases in the home environment: * p = 0.001; ** p = 0.021;
*** Kruskal-Wallis H test; IQR = interquartile range; Mdn = median; n = number of
study
participants
no pre-existing disease; (n = 144)
4 (3)
3 (2)
3 (3)
own pre-existing disease; (n = 93)
4 (2)
4 (3)*
4 (2)**
pre-existing disease in home environment (n = 140)
4 (2)
3 (2)
4 (3)
p-value***
0.157
0.003
0.022
Pregnancy-associated diseases
A total of 177 (46.9%) women reported the presence of pregnancy-associated diseases
(Item #63, [Table 4 ]). Here, women with gestational diabetes
(11.9%) had a significantly higher overall level of stress caused by the COVID-19
pandemic than unaffected women (Item #58; p = 0.006; Mann-Whitney U test).
Table 4
Pregnancy-associated diseases.
Overall level of stress
Mdn (IQR)
p*
Stress related to an own potential COVID-19 disease
Mdn (IQR)
p*
Stress related to potential COVID-19 disease in family and friends
Mdn (IQR)
p*
For subjects with or without pregnancy-associated disease, the median of responses
1 ("no distress") to 7 (“highly distressed”) for items “Overall level of stress related
to the
COVID-19 outbreak” (Item #58), “How distressed are you about your own COVID-19-related
symptoms or potential illness” (Item #25) and “How distressed are you about COVID-19-related
symptoms or potential illness in friends and family” (Item #26) is shown. IQR = interquartile
range; Mdn = median; n = number of study participants; * Mann-Whitney U test (presence
of pregnancy-associated disease: yes versus no)
Gestational diabetes
0.006
0.394
0.510
5 (3)
3 (3)
4 (2)
4 (3)
3 (2)
4 (3)
High blood pressure
0.182
0.186
0.800
4 (2)
3 (2)
4 (2)
4 (2.5)
3 (2)
4 (3)
Cervical shortening
0.110
0.994
0.686
4.5 (3)
3 (3)
4 (3)
4 (3)
3 (2)
4 (3)
Fetal growth retardation
0.600
0.878
0.447
4 (3)
3 (3)
3 (2.5)
4 (3)
3 (2)
4 (3)
Care/support and stress
The question regarding the professional care situation during pregnancy by a gynecologist
or midwife (Item #P5 or Item #8) could be answered with “very well supported” (n = 293),
“somewhat
well supported” (n = 78) and “not very well supported” (n = 6). For the evaluation,
the response options were summarized as “somewhat well supported” and “not very well
supported” (“less
well supported”, n = 84). Regarding the perceived stress levels for the qualities
“overall level of stress” (Item #58), “How distressed are you about your own COVID-19-related
symptoms or
potential illness” (Item #25) and “How distressed are you about COVID-19-related symptoms
or potential illness in friends and family” (Item #26), significantly more stress
was perceived when
the care/support provided was less good ([Table 5 ]).
Table 5
Stress level in relation to the care situation.
Overall level of stress
Mdn (IQR)
Stress related to an own potential COVID-19 disease
Mdn (IQR)
Stress related to potential COVID-19 disease among family and friends
Mdn (IQR)
For subjects with very or less well support, the median of answers 1 (“no distress”)
to 7 (“highly distressed”) is shown for items “Overall level of stress related to
the COVID-19
outbreak” (Item #58), “How distressed are you about your own COVID-19-related symptoms
or potential illness” (Item #25) and “How distressed are you about COVID-19-related
symptoms
or potential illness in friends and family” (Item #26). IQR = interquartile range;
Mdn = median; n = number of subjects; * Mann-Whitney U test
Very well supported; (n = 292)
4 (3)
3(2)
4 (3)
Less well supported; (n = 84)
4.5 (3)
4 (3)
4 (2)
P value*
< 0.001
0.016
0.044
In addition, the respondents stated that the COVID-19 pandemic had weakened support
from their social network (item #42; significant difference to 1 = “not supported”;
p = 0.003; Wilcoxon
test). There was a discrepancy between the demand and supply of digital support services:
60.3% of pregnant women and 44.3% of postpartum women wished to learn more about virtual
mother-child groups (Item #P14 or Item #19), but only 16.1% of postpartum women used
virtual support services (Item #18).
Discussion
The results of this questionnaire-based cross-sectional study show that women found
their general stress levels to be significantly increased during and after pregnancy
due to the COVID-19
pandemic. Pregnant women with pre-existing diseases (e.g., gestational diabetes or
respiratory diseases) reported significantly higher stress levels than women without
relevant pre-existing
diseases. Women who felt less well cared for also reported a significantly higher
level of stress compared to women who felt very well cared for.
These findings largely coincide with results reported in the currently available literature.
For example, Moyer and colleagues (2020) [20 ] also report that women in pregnancy had an increased stress level and increased
pregnancy-associated fears due to the COVID-19 pandemic. The study participants were
predominantly worried about household conflicts, losing their jobs or becoming infected
with COVID-19. Stepowicz and colleagues [30 ] also
found that pregnant and postpartum women showed increased anxiety symptoms during
the COVID-19 pandemic. The stress and anxiety levels were also significantly increased
in women with
pre-existing diseases compared to women without pre-existing diseases. Similar results
were shown by Mappa et al. [26 ], who also
investigated anxiety during pregnancy. It should be emphasized that these two previous
studies were published at the beginning of 2020, at a time when less was known about
COVID-19, the
disease characteristics, the course of disease and the approval of vaccines could
not yet be estimated. We now know that the transplacental infection of the fetus is
rather a rare event and
that the vaccination of pregnant women is classified as safe [31 ]
[32 ]
[33 ]. In addition, the prevalence of a SARS-CoV-2 infection in the context of a pregnancy
was low during the study period [34 ].
Women with pregnancy-related diseases or at-risk pregnancies are a particularly vulnerable
group [35 ]
[36 ]. In the present study, women with gestational diabetes had a significantly increased
perception of stress. There was however no
significant association between the stress experience and gestational hypertension,
cervical insufficiency or fetal growth retardation, although there was only a small
number of cases in each
group. A larger sample size would be required to investigate associations of at-risk
pregnancies and stress during the COVID-19 pandemic in more detail and in particular
to evaluate any
specific correlations with the week of pregnancy at the time of the survey.
Women who found the care situation by a gynecologist or midwife to be less adequate
also described an increased stress level. Considering the influence of support during
pregnancy and after
birth as well as the general social support, a study by Lebel and colleagues in particular
confirms an association with depression and anxiety disorders [24 ]. Among other things, the authors described social support and taking part in sports
as protective factors. Nearly two thirds of respondents wanted more virtual-based
support, although only a small proportion of participants actually used such support
when it was available.
A limiting factor of the present study is that perceived stress was measured at only
one time point during the pandemic period, which proceeded in three waves up till
the time of the
evaluation. This means that the extent that lockdown measures and restrictions influenced
the feeling of stress, for instance, cannot be determined. Given the international
differences between
health care systems and country-specific political decisions on pandemic containment,
cross-national interpretation of the results is limited. In addition, the questionnaire
was only developed
with the emergence of the COVID-19 pandemic and can therefore not be compared to a
control group (consisting of women whose pregnancies and postpartum periods were not
affected by the COVID-19
pandemic). Accordingly, we asked to what extent stress levels were increased by the
COVID-19 pandemic, although it cannot be ruled out that other factors contributed
to a subjectively
increased sense of stress during that period of time. We used a questionnaire from
the international COVGEN initiative that remains to be validated [29 ]
[37 ]. A reference value for the perception of stress is therefore not available. Similarly,
the comparison with a
control group is not possible at the present time, as the effects of the COVID-19
pandemic affect the entire population. Accordingly, we examined the extent to which
the general feeling of
stress significantly differed from the stress scale of “1” (1 = “no stress”). The
drop-out rate due to incomplete questionnaires was particularly high among the online
cohort. A potential
rationale may be that less time was available in the home environment for the online
cohort to complete the questionnaire than in the inpatient context. This can lead
to a distortion of the
results and a corresponding overestimation of the influence of COVID-19 on the stress
experience.
Conclusions
Women during and after pregnancy are particularly affected by COVID-19. The presence
of pregnancy-associated diseases contributes to an increased stress experience due
to COVID-19. In
particular, women with less social support or with pre-existing diseases should be
identified at an early stage in order to provide targeted further support that is
available independently of
lockdown measures.
