Mental health among pregnant women with COVID‐19–related stressors and worries in the United States

1 INTRODUCTION

SARS-CoV-2, the novel coronavirus that causes COVID-19, has caused more than 1 million deaths globally.1 High infectiousness in susceptible populations, the potential for severe disease and death, and the absence of a vaccine early in the pandemic may contribute to increased mental health stress. The anxiety that SARS-CoV-2 triggers stems from factors including fear of contracting COVID-19 and worry about family members, friends, and acquaintances becoming infected.2 Anxiety related to testing, feelings of guilt related to positive diagnosis, and feelings of despair and grief because of deaths within and outside family may also affect mental health. COVID-19 can also detract from mental health because of factors such as loneliness stemming from recommended mitigation strategies (eg, social distancing, quarantine, isolation)3, 4 and COVID-19-related job loss or changes in working location.5

Depression and anxiety are common mood disorders that typically affect one in seven pregnant women.6, 7 During the COVID-19 pandemic, pregnant women represent a uniquely vulnerable group.8, 9 With reduced social support, disruptions in traditional in-person prenatal care visits, and safety concerns about delivering a baby in a hospital,10 we hypothesize that pregnant women may experience heightened depressive symptoms and anxiety.

To date, a growing number of studies have examined the prevalence of depression and anxiety among pregnant women worldwide.11 At least four published studies have examined depression or anxiety among pregnant women living in the United States,12-15 but the inferences are limited as these studies have been limited in scope and/or sample size.12, 13, 15 Furthermore, few studies have directly investigated pregnant women's COVID-19–related stressors (such as income loss, change in medical appointments, and family death), self-reported worries, and social distancing practices in relationship to their mental health,16 although these factors have been evaluated in the general population.17-19 To effectively mitigate the negative impacts that a pandemic can have on women and infants, research is needed to advance understanding of COVID-19–related stressors, worries, and social distancing on the mental health of birthing people. The purpose of this study was to evaluate associations between COVID-19–related experiences and mental health outcomes (ie, depressive symptoms, thoughts of self-harm, and anxiety) among United States pregnant women.

2 MATERIALS AND METHODS 2.1 Study design

We conducted a cross-sectional, online survey of pregnant women early in the pandemic (May 6-8, 2020). The 126-question survey was designed to examine the impacts of the COVID-19 pandemic on pregnancy health, health behaviors, and prenatal care. Before beginning the survey, all participants were screened for the following eligibility criteria: 18-44 years of age, ≥8 weeks’ pregnant, United States residence, and prenatal care status in the United States. The study's protocol was approved by the Institutional Review Board at the University of South Carolina, and all respondents consented to participate. To recruit a diverse sample of pregnant women that oversampled black or African American women, we advertised the study on group Facebook accounts for minoritized pregnant women, and within community health programs that served a large proportion of ethnically and racially diverse families. We capped enrollment for black women at 50% of our target sample size (n = 750).

A total of 881 survey responses were received. After excluding duplicate responses from the same IP address (n = 32) and responses from those whom: (a) did not meet the inclusion criteria (n = 46); (b) did not complete the survey (n = 48) or completed <90% of questions (n = 2); (c) reported an expected due date before the interview date (n = 9); or (d) had missing values for key variables (n = 31), 715 valid survey responses were analyzed.

2.2 Independent variables: COVID-19–related experiences

Adapted from the Pandemic Stress Index,20, 21 COVID-19–related experiences were measured by: (a) COVID-19–related stressors, (b) COVID-19–related worries, (c) social distancing, and (d) changes in working arrangements among household adults. COVID-19–related stressors included the following: (a) family members in or outside the household dying from COVID-19 or related complications; (b) losing a source of income because of COVID-19; and (c) canceled or reduced medical appointments. Six questions were used to evaluate a woman's degree of COVID-19–related worries (Cronbach's α = 0.76 in our study sample) about: (a) their pregnancy, (b) friends and family, (c) stigma or discrimination, (d) having enough basic supplies, (e) getting emotional or social support from family, partners, a counselor, or someone else, and (f) receiving financial support from family, friends, partners, an organization, or someone else. These items measured similar domains (ie, own health, money problems, and relationship with family and friends) used in a validated Cambridge Worry Scale for pregnant women.22 The scale included five response options: not at all (0), a little (1), sometimes (2), most of time (3), and all the time (4). A summary score of all 6 items was created (range: 0-24). Furthermore, women were asked whether they practiced social distancing (ie, reducing their physical contact with other people in social, work, or school settings by avoiding large groups and staying 3-6 feet away from other people). Women who responded “yes, very strictly” were coded as strictly social distancing vs. others (“yes, but not strictly” and “No, I am not”). Finally, the survey asked the number of adults (including the respondent) living in the household and the number of adults in the household who worked from home, who stopped working as a result of COVID-19, and who still worked outside the home despite COVID-19. Using the data, we derived two measures to assess adults’ working arrangements during the pandemic: (a) the percentage of adults working from home; and (b) most adults in the household stopped working as a result of COVID-19 (percentage of adults who stopped working ≥50%).

2.3 Dependent variables: mental health measures

The validated Edinburgh Postnatal Depression Scale (EPDS)6, 23 (Cronbach's α = 0.75 in our sample) was used to screen for depressive symptoms in the 2 weeks before survey completion. Women who scored above 13 based on all 10 items were defined as probable depression.23, 24 The 10th item, thoughts of self-harm (ie, often, sometimes), was analyzed separately because of its severity.

The validated 7-item Generalized Anxiety Disorder Scale (Cronbach's α = 0.85) was used to evaluate anxiety experienced in the last 2 weeks.25 The answer options were “not at all (0),” “several days (1),” “over half the days (2),” and “nearly every day (3).” Respondents with a summary score of all items ≥10 were categorized as experiencing moderate/severe anxiety. This cutoff point has been shown to have good sensitivity and specificity for identifying anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder.25

2.4 Covariates

To control for confounding, the following covariates were considered:26 age, race/ethnicity, education, annual household income, health insurance, employment status, parity, prepregnancy body mass index, pregnancy trimester, any diagnosis of pregnancy complications, and the census region (Northeast, Midwest, South, and West) of residence. Pregnancy complications included high blood pressure, HELLP, gestational diabetes, anemia, placenta previa, or other diagnoses.

2.5 Statistical analyses

We first examined whether depressive symptoms, thoughts of self-harm, or moderate/severe anxiety was related to the above-mentioned covariates using the chi-square tests of independence. The bivariate associations of COVID-19 experiences with each mental health outcome were examined using the chi-square tests for categorical variables and t tests for continuous variables. Multiple logistic regressions were run to examine the associations of all COVID-19–related experiences with each mental health outcome while adjusting for covariates. To examine the robustness of our results and to improve our model efficiency, we also ran a model where we replaced the individual worry items with a summary worry score. Clustered standard errors were used to account for heteroskedasticity across census regions. The variance inflation factor (VIF) was used to examine multicollinearity in regression variables. All analyses were conducted with SAS 9.4 (SAS Institute, Cary, NC, USA).

3 RESULTS

Participants were racially diverse (44.1% non-Hispanic black, 9.4% Hispanic, and 38.9% non-Hispanic white), with representation from all 50 states and Washington, DC. The proportion of sample women residing in the South, West, Midwest, and Northeast census regions was 38.9%, 26.0%, 21.7%, and 13.4%, respectively. The majority of respondents had earned a bachelor's degree (62.8%) or higher (7.6%), worked full-time during pregnancy (64.9%), were multiparous (57.1%), were in the first (34.7%) or second (39.2%) trimester, and were normal weight before their pregnancy (81.1%). Over one-half (51.3%) lived in households with total annual incomes <$50 000 (Table 1).

TABLE 1. Sample characteristics and mental health risk factors All participants Depression Self-harm Anxiety n (%) % P-valuea % P-valuea % P-valuea All, n (%) 715 (100.0) 260 (36.4) 144 (20.1) 157 (21.9) Age, y 18-24 21 (2.9) 66.7 0.0001 28.6 0.20 28.6 0.007 25-29 343 (48.0) 31.8 17.8 16.6 30-34 311 (43.5) 36.3 20.9 26.0 35-40 40 (5.6) 60.0 30.0 32.5 Race/ethnicity Hispanic 67 (9.4) 44.8 <0.0001 32.8 <0.0001 32.8 <0.0001 Non-Hispanic white 278 (38.9) 60.4 30.2 33.1 Non-Hispanic black 315 (44.1) 14.0 9.8 5.4 Non-Hispanic Other 55 (7.7) 32.7 12.7 47.3 Education attainment Lower than bachelor's degree 212 (29.7) 54.2 <0.0001 33.0 <0.0001 33.0 <0.0001 Bachelor's degree 449 (62.8) 26.1 12.0 14.3 Graduate degree 54 (7.6) 51.9 37.0 42.6 Health insurance Private insurance only 465 (65.0) 18.7 <0.0001 8.8 <0.0001 14.6 <0.0001 Medicaid 108 (15.1) 74.1 48.1 38.0 Other insurance 118 (16.5) 65.3 36.4 33.1 No insurance 24 (3.4) 66.7 33.3 37.5 Employment status Full-time employed 464 (64.9) 22.8 <0.0001 11.4 <0.0001 15.7 <0.0001 Part-time employed 128 (17.9) 58.6 44.5 39.8 Out of work/homemaker 123 (17.2) 64.2 27.6 26.8 Parity Primiparous 307 (42.9) 48.5 <0.0001 25.7 0.001 28.0 0.0007 Multiparous 408 (57.1) 27.2 15.9 17.4 Trimester 1st Trimester 248 (34.7) 21.0 <0.0001 11.3 <0.0001 9.7 <0.0001 2nd Trimester 280 (39.2) 38.2 19.3 23.9 3rd Trimester 100 (14.0) 40.0 15.0 34.0 Don't know 87 (12.2) 70.1 54.0 36.8 Prepregnancy BMI Underweight 64 (9.0) 54.7 0.004 29.7 0.04 21.9 <0.0001 Normal 580 (81.1) 34.0 19.7 19.5 Overweight/obese 71 (9.9) 39.4 15.5 42.3 Any pregnancy complications No 580 (81.1) 29.1 <0.0001 14.1 <0.0001 17.1 <0.0001 Yes 135 (18.9) 67.4 45.9 43.0 Census regions Northeast 96 (13.4) 39.6 0.11 26.0 0.09 19.8 0.52 Midwest 155 (21.7) 33.5 16.8 25.2 South 278 (38.9) 32.0 17.3 19.8 West 186 (26.0) 43.6 24.2 23.7 Abbreviation: BMI, body mass index. a P-values were based on the chi-square tests of independence.

Approximately 36% of women suffered from probable depression during pregnancy. One in five pregnant women reported thoughts of harming themselves. Nearly 22% of women reported anxiety during pregnancy (Table 1). More than two out of five (43.3%) women were identified as having probable depression or anxiety or both during pregnancy. Women with probable depression were more likely to report thoughts of self-harm than women who were not depressed (53% vs 1.3%). These women were also more likely to have symptoms of anxiety (41.5% vs 10.8%; data not shown). The percentages of probable depression, self-harm, and anxiety in each subcategory of sample characteristics are summarized in Table 1.

3.1 COVID-19–related experiences

Early in the pandemic, 6% of pregnant women reported that one family member inside or outside their household died from COVID-19. About one-fourth (27.6%) of women reported lost income because of the COVID-19 pandemic, and nearly 60% canceled or reduced medical appointments (Table 2). On a 0-4 scale with 4 being the most worry, on average, pregnant women expressed low to moderate levels of worry, but worried most frequently about their friends and family (mean response 2.2), their pregnancy (2.1), having enough basic supplies (1.9), stigma or discrimination (1.8), and worried slightly less about getting emotional or social support (1.5) or financial support (1.4). Among pregnant women, 61.3% reported strictly practicing social distancing. Pregnant women reported that an average of 71.8% of adults in their households were working from home because of COVID-19; 17.3% of adults stopped working as a result of the pandemic, and 10.7% of adults continued to work outside the home (Table 2).

TABLE 2. COVID-19–related experiences and depression in pregnant women COVID-19 Experiences All Depressed Not depressed Mean ± SD or % P-valuea aOR (95% CI)b All, n (%) 715 (100.0) 260 (36.4) 455 (63.6) COVID-19–related stressors Family members died from COVID-19 No 672 (94.0) 33.0 67.0 <0.0001 1.0 Yes 43 (6.0) 88.4 11.6 2.9 (0.7-12.2) Lost source of income No 518 (72.4) 23.4 76.6 <0.0001 1.0 Yes 197 (27.6) 70.6 29.4 1.2 (0.5-3.0) Canceled or reduced medical appointments No 281 (40.1) 38.1 61.9 0.35 1.0 Yes 419 (59.9) 34.6 65.4 1.3 (1.1-1.5) COVID-19–related worries, range 0-4 Worrying about….. Your pregnancy 2.1 ± 0.9 2.3 ± 1.1 2.0 ± 0.9 0.0003 1.2 (1.1-1.4) Your friends and family 2.2 ± 1.0 2.3 ± 1.1 2.1 ± 0.9 0.009 0.8 (0.7-1.0) Stigma or discrimination 1.8 ± 1.1 2.1 ± 1.1 1.7 ± 1.0 <0.0001 1.2 (0.9-1.5) Having enough basic supplies 1.9 ± 1.0 2.2 ± 1.0 1.8 ± 0.9 <0.0001 1.1 (0.8-1.5) Getting emotional or social support 1.5 ± 1.2 2.2 ± 1.1 1.1 ± 1.1 <0.0001 2.1 (1.5-3.1) Getting financial support 1.4 ± 1.2 2.1 ± 1.1 1.0 ± 1.1 <0.0001 1.2 (1.2-1.3) Strictly social distancing No 277 (38.7) 34.3 65.7 0.36 1.0 Yes 438 (61.3) 37.7 62.3 1.3 (1.0-1.6) Adults working arrangement in a household % of adults working from home 71.8 ± 33.1 51.0 ± 31.8 83.5 ± 27.7 <0.0001 0.8 (0.7-1.0) Adults stopped working ≥50%d No 573 (81.9) 29.8 70.2 <0.0001 1.0 Yes 127 (18.1) 64.6 35.4 0.8 (0.5-1.4) Abbreviations: aOR, adjusted odds ratios; CI, confidence interval; SD, standard deviation. a P-values were based on the chi-square tests of independence for categorical variables or t tests for continuous variables. b The multiple logistic regression model adjusted for all COVID-19 experiences listed in the table plus additional adjustment of age (categorical), race, education, health insurance, employment, parity, prepregnancy BMI categories, pregnancy trimester, any diagnosis of pregnancy complications, and census region. Odds ratios for covariates are presented in Table S1. Odds ratios in bold face are statistically significant at the 0.05 level. Sample size for the model was 649. c aOR was measured per 10 percentage increase. d The sample size was 700 because of missing values. 3.2 Associations between COVID-19 experiences and mental health 3.2.1 Depression

As shown in Table 2, after adjusting for all covariates and other COVID-19 experiences, depression was significantly higher among women who canceled or reduced medical appointments (adjusted odds ratio [aOR] 1.3 95% confidence interval [95% CI] 1.1-1.5) compared with those who did not have such experiences. The odds of depression was highest among those who reported worrying about getting emotional or social support (2.1 [1.5-3.1]), followed by worrying about the pregnancy (1.2 [1.1-1.4]) and worrying about getting financial support (1.2 [1.2-1.3]). Strict social distancing was also associated with higher odds of depression (1.2 [1.0-1.6]). Each 10-percent increase in adults working from home was associated lower odds of depression (0.8 [0.7-1.0]).

3.2.2 Thoughts of self-harm

Losing a family member because of COVID-19 (4.2 [2.8-6.4]) and worrying about getting financial support (2.1 [1.3-3.6]) were positively associated with thoughts of self-harm (Table 3). Adults working from home were inversely associated with thoughts of self-harm (0.8 [0.7-0.9]).

TABLE 3. COVID-19–related experiences and thoughts of self-harm in pregnant women Self-Harm No self-harm P-valuea aOR (95% CI) b Mean ± SD or % All, n (%) 144 (20.1) 571 (79.9) COVID-19–related stressors Family members died from COVID-19 No 16.5 83.5 <0.0001 1.0 Yes 76.7 23.3 4.3 (2.8-6.4) Losing source of income No 11.6 88.4 <0.0001 1.0 Yes 42.6 57.4 1.2 (0.3-5.0) Canceled or reduced medical appointments No 22.4 77.6 0.14 1.0 Yes 17.9 82.1 1.2 (0.7-1.9) COVID-19–related worries, range 0-4 Worrying about….. Your pregnancy 2.2 ± 1.1 2.1 ± 1.0

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