key: cord-0769986-r2hpg7aq authors: Choi, Kristen; Records, Kathryn; Low, Lisa Kane; Alhusen, Jeanne L.; Kenner, Carole; Bloch, Joan Rosen; Premji, Shahirose Sadrudin; Hannan, Jean; Anderson, Cindy M.; Yeo, Seonae; Cynthia Logsdon, M. title: Promotion of Maternal–Infant Mental Health and Trauma-Informed Care During the Coronavirus Disease 2019 Pandemic date: 2020-08-12 journal: J Obstet Gynecol Neonatal Nurs DOI: 10.1016/j.jogn.2020.07.004 sha: 6f1c0614f130ea518837a9cd78beeddca4165801 doc_id: 769986 cord_uid: r2hpg7aq The coronavirus disease 2019 pandemic has led to disruptions in health care in the perinatal period and women’s childbirth experiences. Organizations that represent health care professionals have responded with general practice guidelines for pregnant women, but limited attention has been devoted to mental health in the perinatal period during a pandemic. Evidence suggests that in this context, significant psychological distress may have the potential for long-term psychological harm for mothers and infants. For infants, this risk may extend into early childhood. In this commentary, we present recommendations for practice, research, and policy related to mental health in the perinatal period. These recommendations include the use of a trauma-informed framework to promote social support and infant attachment, use of technology and telehealth, and assessment for mental health needs and experiences of violence. , the 2020 coronavirus pandemic (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], which causes coronavirus disease 2019 ) has dramatically affected women's experiences of pregnancy, birth, and early parenthood and their access to perinatal health care services. Emerging evidence suggests Q4 that pregnant women are at similar risk for contracting COVID-19 as the general population and for having more severe disease courses, but the research is still evolving, and many unanswered questions about the effects of COVID-19 on childbearing women and infants remain, such as the long-term effects of COVID-19 on fetal development, infant development, and reproductive health (Liu et al., 2020; Qiao, 2020; World Health Organization [WHO] , 2020; Yan et al., 2020) . It is not yet known whether the virus can be transmitted to a fetus during pregnancy or to an infant during birth and breastfeeding (Schwartz et al., 2020; WHO, 2020; Yan et al., 2020) . Based on early evidence and caution, public health officials and organizations that represent health care professionals and government organizations have rapidly developed guidelines for the clinical care of pregnant women that use infection control precautions (Centers for Disease Control and Prevention [CDC], 2020; Liang & Acharya, 2020; Luo & Yin, 2020 ; see Table 1 ). Government health entities, including the CDC and WHO, should be consulted for the most current research and recommendations. Although current evidence remains insufficient to suggest that there is greater risk for severe COVID-19 illness for pregnant women than the general population, there is consensus among these organizations that careful infection control precautions are warranted, given the many unknowns about COVID-19 and pregnancy. Currently, the CDC and WHO recommended that COVID-19 testing should be prioritized for pregnant women with symptoms or known exposure and that isolation of infants with confirmed infections should be considered on a case-by-case basis (CDC, 2020; WHO, 2020) . Guidelines from professional organizations provide additional information for nurses and other health care professionals about how to approach clinical care and minimize risk for virus transmission in perinatal care settings. 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 Limited guidance is available related to maternal and infant mental health during a pandemic. Understanding how to approach infection control and disease management among childbearing women and infants is an immediate priority for perinatal nurses. However, an equally important aspect of the COVID-19 pandemic is its effect on the mental and emotional health of childbearing women and infants (Topalidou et al., 2020; Xiang et al., 2020; Zeng et al., 2020) . Clinicians and experts are raising concerns about the Assess for COVID-19-specific anxiety, stress, and other psychological symptoms (Lee, 2020) Encourage the use of mindfulness as a strategy to reduce stress and to support control over aspects of pregnancy that can be addressed, such as positive health behaviors and using positive cognitive framing. Facilitate technology-based mechanisms for family and support person interactions, such as telephone and video calls Promote skin-to-skin contact (e.g., skin-to-skin care) and breastfeeding to the extent safely possible Observe infants who are separated from mothers for excessive stress and ensure that human touch is provided to these infants Reevaluate psychological symptoms (stress, depression, anxiety), support systems, and safety upon discharge to assess for community care needs For women with mental health disorders, determine if behavioral health care has been interrupted; consider a behavioral health consult before the woman is discharged for follow-up care and medication refills as needed Early Parenthood Use virtual methods of follow-up to screen for postpartum depression, anxiety, and posttraumatic stress symptoms in the first days and 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 pandemic's potential to cause far-reaching harm to the mental health of women and infants. During the pandemic, women are at increased risk for depression, anxiety, posttraumatic stress disorder, and suicidality precipitated by new pandemic-related stressors (Thapa et al., 2020) . These negative mental health effects may occur as a result of distress from infection or hospitalization of family members; traumatic loss and bereavement from COVID-19 deaths; increased caregiving demands for children and family members who are spending more time at home; isolation from community due to social distancing, job loss, and financial hardship related to closure of nonessential businesses; increased interpersonal stressors or relationship violence secondary to pandemic stressors; and uncertainty about the future (Shah et al., 2020) . The short-and long-term psychological effects of the pandemic have the potential to disproportionately harm women from marginalized and underresourced communities. These may include underrepresented minority communities in which there is strong evidence of disparities in rates of infection and mortality, communities with undocumented immigrant residents, communities with limited access to technology and health care resources, and communities that experience housing instability or homelessness (Gross et al., 2020) . Researchers have found strong negative psychological effects of pandemics on childbearing women. Previous pandemics were associated with negative emotional states, anxiety about infection risk, disrupted routines, disruption of health care, financial and occupational concerns, and increased caregiving demands (Brooks et al., 2020) . Similar evidence is emerging from the COVID-19 pandemic related to greater rates of depression, anxiety, and stress among the general population (54% of 1,210 respondents to a survey in China; Wang et al., 2020) and, specifically, among mothers of infants and young children (Cameron et al., 2020) . Among pregnant women with no preexisting mental disorders in Italy (N ¼ 100), more than 50% indicated that the pandemic had a severe psychological effect on their wellbeing and reported greater levels of anxiety (Saccone et al., 2020) . Anxiety was more severe for women in the first trimester of pregnancy (Saccone et al., 2020) . Psychological distress among pregnant women appears to be driven by uncertainty and concern for older relatives, unborn children, other children, and their own health (Corbett et al., 2020) . Given early evidence for psychological harm to pregnant women and the potential for lasting effects among new parents and infants, there is a need for nurses to address maternal mental health across all aspects of the perinatal care continuum. Our recommendations for clinical practice are shown in Table 2 . These recommendations cover the entire perinatal care continuum and provide nurses and other members of the maternity care team with direction for fostering social support, performing relevant mental health and safety assessments, and offering patient-centered education (resources for women can be found in Table 1 ) specific to uncertainty and unexpected care experiences that result from the pandemic. Because separation of mothers from infants can lead to negative growth and development and impaired bonding (Bartick, 2020; Bystrova et al., 2009; Stuebe, 2020) , we recommend mothers and infants be kept together whenever safely possible. We recommend a trauma-informed approach to perinatal care for women and infants during the pandemic in consideration of the elevated potential for fear, anxiety, stress, grief, and other signs of psychological distress. A traumainformed care approach involves recognizing and responding to these and other symptoms of trauma and actively seeking to avoid triggers and retraumatization while providing care (Substance Abuse and Mental Health Services Administration, 2014). Nurses can provide trauma-informed care during a pandemic by promoting women's control and choice whenever possible, acknowledging the effects of COVID-19 on their births and early parenting experiences, Early evidence suggests that the COVID-19 pandemic has had an adverse effect on the mental health of pregnant women and mothers, including depression, anxiety, and stress. Choi, K. et 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 and using a collaborative approach to ensure that their mental, physical, emotional, and social needs are met. This approach should be sustained beyond the pandemic because growing evidence suggests the value of and critical need for trauma-informed care for individuals who have experienced prior birth trauma, have histories of adverse childhood events, or have had negative life experiences that contribute to traumatic stress (Seng et al., 2009) . Nurses are uniquely positioned to provide these maternal and infant health interventions as members of the perinatal care team. They often have sustained contact and relationships with women and their infants during the continuum of maternity care. By using a trauma-informed perspective and addressing mental health needs, nurses can promote positive mother and infant outcomes in the midst of pandemic stressors. As nurses respond to maternal and infant mental health needs in clinical practice, it is important that nurse-scientists and leaders also address these issues through research and policy initiatives. A COVID-19 maternal mental health research agenda should include the following (Holmes et al., 2020) : use of population-based data sets to better understand the effects of COVID-19 on perinatal, neonatal, and early childhood mental health outcomes, including the effects of separation and social distancing secondary to mother-to-infant virus transmission on early child development and maternal-infant attachment; documentation and development of interventions to address disparities in mental health outcomes, with attention to the intersection of COVID-19 and social determinants of health, including systemic racism; evaluation of the international response to COVID-19 for pregnant women, infants, and perinatal nurses across countries and the effect of local systems of care on perinatal outcomes; investigation of the short-and long-term reproductive and mental health outcomes of nurses and other frontline workers who are at increased risk for exposure to COVID-19; exploration of opportunities to use risk assessment models that provide the optimal level of care for family needs, including home birth and birth center models of care; evaluation of telehealth care models as an intervention to improve access to perinatal care (e.g., reduce transportation or childcare barriers); and development and testing of virtual social support interventions to promote maternal mental health and positive early parenting, including the use of virtual platforms for their delivery. Nurses should advocate for the development of strong nursing and public health care workforces Q5 in the United States, federal funding for maternal and infant mental health research and nursing workforce development, protection against the occupational hazards of providing health care in a pandemic, and payment models that support virtual care and innovative mental health and parenting interventions. Nurse clinicians, scientists, and system leaders are ideally positioned to address evolving maternal and infant mental health needs in the COVID-19 pandemic. Our collective action is vital to a comprehensive pandemic response. By acting to ensure that the mental health needs of women and infants are met, nurses will help ensure population resilience in the COVID-19 pandemic and beyond. To promote mental health in the perinatal period, nurses should foster social support and infant attachment, use technology, assess for safety needs, and provide traumainformed care. 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