Why Mental Health Matters for a Healthy Pregnancy: COVID-19 Survey

Having a baby comes with its fair share of stress. And more than a hundred million babies have been born around the world since COVID-19 was first declared a pandemic. So researchers wanted to know: How are pregnant and postpartum individuals fairing mentally during this stressful time?

In a worldwide survey, pregnant and postpartum women reported high levels of depression, anxiety, loneliness, and post-traumatic stress during the early stages of the COVID-19 pandemic. The study was published in the PLOS One journal in late April.

“A lot of women had really significant distress, whether you think about it as PTSD, anxiety, depression, or loneliness,” study author Karestan Koenen, PhD, a professor of psychiatric epidemiology at the Harvard T. H. Chan School of Public Health, tells Verywell. “In many cases, a range from 40 to 50% of women [were] reporting significant distress.”

Similarly, Forough Mortazavi, PhD, professor of reproductive health at the Sabzevar University of Medical Sciences in Iran, saw pregnant women coping in a number of ways through her own research. “During the first few weeks, some women did not leave the house for a month, and some would not even let the husband go to work,” she tells Verywell.

“Periods of extreme maternal distress have been linked to effects on the development of the child across the lifespan,” Mortazavi adds. Experts say policy changes and mental health screens can potentially help alleviate some of these issues.

Increased Mental Health Strain

The researchers from Harvard advertised their anonymous survey for pregnant and postpartum individuals on social media and online parenting forums between May 26, 2020, and June 13, 2020. The survey, available in 12 languages, reached 6,894 women in 64 countries, including all continents except Antarctica.

Participants recorded information such as demographics, COVID-19 exposure, and worries, as well as their information-seeking behavior (like reading or watching the news), COVID-19 prevention behaviors, and loneliness. To measure any mental health symptoms, researchers also incorporated scales used to diagnose post-traumatic stress, anxiety, and depression disorders.

Of the almost 7,000 participants, most (86%) reported being somewhat or very worried about COVID-19. Many also scored at or above the cut-offs for:

• Loneliness (53%)
• Elevated post-traumatic stress (43%)
• Anxiety/depression (31%)

All of these rates exceed those found in the general population, as well as in pregnant and postpartum individuals when not in pandemic times, the authors note.

The most commonly reported worries among participants were related to:

• Pregnancy and delivery, including family being unable to visit after delivery (59%)
• Baby contracting COVID-19 (59%)
• Lack of a support person during delivery (55%)
• COVID-19 causing changes to the delivery plan (41%)

Researchers also identified relationships between behaviors and symptoms. For example, information seeking from any source, whether through social media, news, or talking to others, five or more times a day was associated with elevated post-traumatic stress and anxiety/depression. At the same time, researchers did not find a relationship between practicing hygiene-related prevention behaviors such as mask-wearing and mental health symptoms or loneliness. 

A Doula’s Perspective

Echoing the survey results, Leila Xinle Ng Caceres, a DONA-certified doula currently based in Singapore, tells Verywell that in her work, she’s witnessed many women worry about catching the virus and passing it on to their children, as well as whether their families will be able to visit the newborn.

When it comes time for birth, Caceres adds, many fear that partners, parents, friends, and/or personal doulas won’t be able to be in the delivery wards with them to support the labor process. Smaller factors, too, could add unprecedented stress. “Some hospitals needing mothers to push with a mask on—that was really tough, to be honest,” she says.

For those who aren’t first-time parents, Caceres adds, juggling work, home-based learning, and pregnancy all at once can pose challenges.

The scope of the study shows how women around the world are facing similar worries even when their perinatal cultural norms differ. “In Asia, some women hire confinement nannies to help out with babies and moms for the first month or two,” Caceres says. “During COVID times with border closures, some of the Malaysian confinement nannies were not able to come out. This caused a lot of worries and stress to the mothers to be.”

Can Extreme Maternal Stress Affect Babies?

Extreme stress during pregnancy is associated with the development of emotional and/or cognitive difficulties, asthma, and even schizophrenia. Distress can also complicate the perinatal period, leading to preeclampsia, preterm birth, low birth weight, and even infant mortality.

While every human being inherits DNA from their parents, an emerging field in genetics, termed “epigenetics,” explores how genes express themselves based on their environment. If someone faces undue stress during the prenatal period, the stress could impact the uterine environment, and in turn, the fetus.

One noted example of prenatal epigenetics at work includes the Dutch Hunger Winter, when Nazi forces “punished the Netherlands” by blocking trains delivering food supplies in September 1944.

Women who were pregnant during this time not only suffered themselves; their offspring were born underweight, and more likely to have certain health problems later in life. Compared to siblings born before or after the months-long famine, the “Hunger Winter children” were at increased risk for obesity. Associations were also found between increased LDL cholesterol in the blood, diabetes, and schizophrenia. Children of people who experienced other famines also experienced a greater risk of developing obesity.

While the COVID-19 pandemic involves unique stressors separate from famines, epigenetic studies suggest that stress felt by mothers during this time can have effects on their offspring.

“We know that maternal mental health, stress, and trauma affect fetal development,” Koenen says. “So, to me, it just highlights the importance of what we’re studying.”

Providing Support

Treating and drawing attention to elevated mental health symptoms in pregnant and postpartum women during the pandemic can potentially alleviate stresses for them and their children.

Specifically, the authors recommend that healthcare systems offer screening and monitoring of symptoms, as well as refer patients to strategies that target loneliness, such as online support groups.

On a larger scale, the authors write, “public health campaigns and medical care systems need to explicitly address the impact of COVID-19 related stressors on mental health in perinatal women, as prevention of viral exposure itself does not mitigate the pandemic’s mental health impact.”

Koenen says lasting policy can make the greatest change.

“What if we recognize as a society that mental health is the foundation of all health?” Koenen asks, suggesting that mental health be addressed in primary care appointments. “There, they do all these checks. They check your BMI. They take your blood pressure. What would a mental health checkup look like?”

Mortazavi adds that most pregnant women need psychological support during crises and that some are likely to need urgent attention, including:

• First-time mothers
• Low-income mothers
• Mothers with a history of abortion
• Those with a COVID-19 infected person among relatives
• Those under 30
• Those with severe fear of COVID-19

Pregnant women should be screened for mental health during emergencies. “This can be done by call centers in the early stages of crises, and referring women with high levels of worry to counselors,” she says.

“If I could go back to the first week of the pandemic, I would promptly create a virtual [support] group to help pregnant women coping with the various challenges, and offer them advice and up-to-date information on COVID-19,” Mortazavi adds. “I would also try holding virtual childbirth preparation classes. We did both of these during the pandemic with delay, but with good results.”

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