Pregnancy is always a time of heightened anxiety, but in the age of global pandemic, women are facing unprecedented stressors. Between 10-20% of women experience postpartum depression/anxiety, and for up to 30% of women, symptoms can actually begin during the pregnancy. Perinatal mood disorders have been associated with worse maternal and neonatal outcomes such as increased rates of preterm birth, decreased rates of breastfeeding, impaired infant bonding, and abnormal infant and child development – many of which come with steeper costs.

Certain risk factors for postpartum mood disorders may be exacerbated by the current pandemic including fear of childbirth, poor social and financial support, stressful life events, and adverse pregnancy outcomes. Additionally, recommended coping techniques including reaching out to family and friends for support, getting out of the house, making time for oneself, and exercising may be difficult to accomplish due to social distancing requirements and stay at home orders. Current treatment and counseling resources may also be more limited than in normal times.

The human and economic costs of untreated maternal mental health issues are meaningful, and these outcomes only stand to be intensified by the added stressors of Covid-19 – concerns about the way the virus will impact prenatal care, hospitals continuing to change their visitation policies, and so many unknowns surrounding the impact of the virus on pregnant women and babies. For some women, higher risks of intimate partner violence compound this situation. With these increased stressors, there is cause for concern that maternal mental health could emerge as a secondary public health crisis, the scope of which we may not realize for years to come.

Adjusting to a new normal for prenatal care
Prenatal care has been transformed in recent months due to the pandemic. While some of these changes, like embracing telemedicine for routine prenatal appointments, are arguably for the better, this certainly provokes anxiety for many women who had a set plan for how their pregnancy and prenatal care would look.

Studies have shown that telemedicine appointments are safe for routine prenatal appointments that don’t require ultrasound, lab work or cervical checks, especially for low-risk pregnancies. A medical study showed that a hybrid of in-person and videoconference prenatal visits for low-risk obstetric patients had similar pregnancy outcomes to the traditional in person visits. The American College of Obstetrics and Gynecology (ACOG) and the Society of Maternal Fetal Medicine have also recommended decreasing the number of ultrasounds to lessen the possible risk of transmission of COVID-19. Patients are now screened for the infection prior to appointments, and visitors are often not allowed in with them even for long-awaited ultrasounds.

Decreased access to typical in-person providers can also lead to increased anxiety for many women. For some patients, this may happen if their in-person provider is called to be a laborist on labor and delivery and for others it could be because their provider themselves is ill with Covid-19. Other women are not yet as comfortable with virtual appointments. Meanwhile other expectant mothers in areas more highly affected by Covid-19 are reluctant to even come into the office for necessary in-person appointments as they fear contracting the virus and what that could mean for their pregnancy. This is problematic, as inconsistent prenatal care has been linked to adverse pregnancy outcomes including low birth weight, preterm labor, and stillbirth. Providers should be aware of these concerns, reassure patients of all of the measures being taken to prevent the spread of infection during in person appointments, and take time to explain to patients the reasoning behind the use of telemedicine for routine appointments.

Concerns about Covid-19’s impact on health outcomes
SARS-CoV-2, the virus that causes Covid-19, has only been in circulation since late November/early December, and not much is known about how this virus affects pregnant women and their unborn children. Early studies have shown that pregnant women are not at higher risk for contracting the virus and do not have a worsened clinical course. However, based on the immunologic changes of pregnancy and observations from other respiratory viruses including influenza, SARS, and MERS, it is possible that pregnant women are at increased risk of developing severe pneumonia from SARS-CoV-2. Initial case series also showed no vertical (mother to baby) transmission, but recent evidence shows that it may be possible, with one case study showing an infant born with positive antibodies to the virus. SARS and MERS, also coronaviruses, were associated with adverse pregnancy outcomes including preterm labor, intrauterine growth restriction, increased risk of NICU admissions, increased risk of miscarriage, and stillbirth.

While it is unclear whether or not Covid-19 infections are associated with adverse pregnancy outcomes (a large trial including infected pregnant women is ongoing), obstetricians are seeing an uptick in second and third-trimester pregnancy losses, and a case study was recently reported in the literature of a second-trimester pregnancy loss caused by a placental infection with SARS-CoV-2 infection. There are still so many unknowns, and it’s this uncertainty that is driving increased anxiety and impacting mental health overall.

Shifting birth plans and adapting to changing hospital policies
Many women have been forced to reevaluate their birth plans, for fear of contracting the virus while in the hospital, as well as concerns about delivering alone due to changing hospital visitation policies. Early on in New York, some hospitals stopped allowing visitors altogether. Thankfully most hospitals are now allowing a single visitor for laboring women, with only a few requiring the support person to leave after delivery. Some hospitals are screening for Covid-19 infection with temperature and symptoms checks while others are choosing to test all pregnant women and their partners. If a support person screens or tests positive, he or she will not be allowed in the delivery room, while if a laboring woman screens or tests positive, the recommendation is separation from the baby after birth to prevent neonatal infection. Women who are fearful of delivering alone or being separated from their baby have sometimes chosen to deliver at an alternate hospital or have not truthfully disclosed when they or their partner have experienced symptoms of coronavirus infection, which can put medical personnel at risk.

Intimate partner violence
For far too many women, the trauma of intimate partner violence intensifies mental health conditions. Intimate partner violence is more common during pregnancy than when a woman is not pregnant, with approximately 324,000 pregnant women in the United States experiencing abuse each year. Often abuse starts for the first time when a woman becomes pregnant. With increased social isolation and fear of coronavirus infection, experts have cause for concern that intimate partner violence is increasing during Covid-19 stay at home orders, as it has during previous pandemics and other natural disasters. Many women are afraid to report abuse to begin with, and with safety nets breaking down, schools closed, and fewer in-person medical appointments, the risks are heightened. Joblessness and financial strain as well as multiple people in a household spending large amounts of time quarantined together increases tension that can lead to increased violence.

Empowering providers with solutions
As the pandemic continues, we as the medical community can take steps to ensure we’re effectively identifying and treating mental health issues, and helping women during this unprecedented time:

  1. Screening – ACOG recommends screening all women during pregnancy for mood disorders and performing comprehensive screening for postpartum depression at the postpartum visit. It is imperative that all pregnant and postpartum women continue to be screened for postpartum depression and mood disorders even when appointments occur virtually and that appropriate resources are available for treatment of mental health disorders. ACOG also recommends screening every woman for intimate partner violence at the first prenatal visit, at least once per trimester, and postpartum. However, during this pandemic increased screening may be warranted.
  2. Referring – Obstetric providers should be referring patients appropriately when screening is positive. A list of mental health providers, intimate partner violence counselors, and shelters in each provider’s area should be readily available, and each provider should be aware of how referrals are being handled during the pandemic.
  3. Listening – Obstetric providers should make time to talk to women at each prenatal appointment, whether in person or remote, about specific concerns or anxieties that they have around the pandemic and be ready to address those concerns. Providers should discuss birth plans with women as due dates near, and discuss new changes in hospital policies surrounding visitors, masks, and COVID-19 testing at the same time reassuring patients that they will be well cared for.
  4. Embracing Telemedicine and Other Virtual Platforms – Newer telemedicine platforms are available to fill in the gaps in between visits and are increasingly covered as a benefit by employers. These can provide mental health counseling, mental health prescriptions, and obstetric education by nurse midwives and obstetricians as well as subspecialists. Some also have a variety of provider types including pediatricians, lactation consultants, physical therapists, and back to work coaches. During the birth, video platforms should be offered to allow additional people (including a doula) to be virtually present in the delivery room if the patient chooses.

Now more than ever, women and families need comprehensive care that supports both physical and mental health. By utilizing all available resources, and tapping into what we know about how best to screen and treat maternal mental health issues, we can help mitigate the risks and preserve the care of our women and families – during the pandemic and beyond.

Photo: damircudic, Getty Images

 



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