key: cord-0804989-jko86vgq authors: Ceulemans, Michael; Foulon, Veerle; Ngo, Elin; Panchaud, Alice; Winterfeld, Ursula; Pomar, Léo; Lambelet, Valentine; Cleary, Brian; O'Shaughnessy, Fergal; Passier, Anneke; Richardson, Jonathan L.; Hompes, Titia; Nordeng, Hedvig title: Mental health status of pregnant and breastfeeding women during the COVID‐19 pandemic—A multinational cross‐sectional study date: 2021-02-13 journal: Acta Obstet Gynecol Scand DOI: 10.1111/aogs.14092 sha: 184024e0a06f2c6f5e8b45eb7516e1a0577262cf doc_id: 804989 cord_uid: jko86vgq INTRODUCTION: Evidence on perinatal mental health during the coronavirus disease 2019 (COVID‐19) pandemic and its potential determinants is limited. Therefore, this multinational study aimed to assess the mental health status of pregnant and breastfeeding women during the pandemic, and to explore potential associations between depressive symptoms, anxiety, and stress and women's sociodemographic, health, and reproductive characteristics. MATERIAL AND METHODS: A cross‐sectional, web‐based study was performed in Ireland, Norway, Switzerland, the Netherlands, and the UK between 16 June and 14 July 2020. Pregnant and breastfeeding women up to 3 months postpartum who were older than 18 years of age were eligible. The online, anonymous survey was promoted through social media and hospital websites. The Edinburgh Depression Scale (EDS), the Generalized Anxiety Disorder seven‐item scale (GAD‐7), and the Perceived Stress Scale (PSS) were used to assess mental health status. Regression model analysis was used to identify factors associated with poor mental health status. RESULTS: In total, 9041 women participated (including 3907 pregnant and 5134 breastfeeding women). The prevalence of major depressive symptoms (EDS ≥ 13) was 15% in the pregnancy cohort and and 13% the breastfeeding cohort. Moderate to severe generalized anxiety symptoms (GAD ≥ 10) were found among 11% and 10% of the pregnant and breastfeeding women. The mean (±SD) PSS scores for pregnant and breastfeeding women were 14.1 ± 6.6 and 13.7 ± 6.6, respectively. Risk factors associated with poor mental health included having a chronic mental illness, a chronic somatic illness in the postpartum period, smoking, having an unplanned pregnancy, professional status, and living in the UK or Ireland. CONCLUSIONS: This multinational study found high levels of depressive symptoms and generalized anxiety among pregnant and breastfeeding women during the COVID‐19 outbreak. The study findings underline the importance of monitoring perinatal mental health during pandemics and other societal crises to safeguard maternal and infant mental health. Since December 2019, the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID- 19) , has spread worldwide. To slow down the transmission of the virus and effectively control the pandemic, exceptional and unprecedented measures were taken by policymakers across countries, such as the closure of workplaces, schools, shops, recreational facilities, bars, and restaurants. 1 These public health measures restricted individuals' liberty and affected every part of society. 2 The potential impact of the COVID-19 pandemic on mental health should not be neglected, especially in vulnerable populations. 3, 4 Pregnant and breastfeeding women are facing numerous life changes that make them particularly vulnerable to mental health disorders. According to the World Health Organization, about 10% of pregnant women and 13% of (recent) mothers experience a mental disorder, primarily depression. 5 A large multinational study on perinatal mental health conducted before the COVID-19 era showed that between 4% and 8% of women have moderate-to-very severe depressive symptoms during pregnancy and in the postnatal period. 6 In the context of the COVID-19 pandemic, maternal distress might be compounded by concerns and fears regarding the risk of infection or hospitalization due to COVID-19, especially as perinatal morbidity and mortality associated with COVID-19 have been described. [7] [8] [9] Maternal depressive symptoms, anxiety, and stress have been associated with adverse pregnancy, fetal, and (long-term) infant outcomes. [10] [11] [12] Therefore, it is critical that mental health disorders are detected and addressed in clinical practice. The extent to which pregnant and breastfeeding women have been emotionally affected by the pandemic remains under-explored. Previous publications have observed an increased likelihood of depressive symptoms and anxiety among pregnant and postpartum/ breastfeeding cohorts during the early stages of the pandemic. [13] [14] [15] However, these studies were limited by relatively small sample sizes and/or individual settings or countries. This highlights the need for larger, multinational studies. In addition, it remains unclear which women are at risk of being emotionally affected. Identifying determinants associated with an increased risk of or protection from mental distress is vital to guide the development of effective prevention and intervention strategies. Therefore, the aim of this study was to assess the mental health status of pregnant and breastfeeding women living in several countries across Europe during the pandemic, and to through social media and hospital websites. The Edinburgh Depression Scale (EDS), the Generalized Anxiety Disorder seven-item scale (GAD-7), and the Perceived Stress Scale (PSS) were used to assess mental health status. Regression model analysis was used to identify factors associated with poor mental health status. In total, 9041 women participated (including 3907 pregnant and 5134 breastfeeding women). The prevalence of major depressive symptoms (EDS ≥ 13) was 15% in the pregnancy cohort and and 13% the breastfeeding cohort. Moderate to severe generalized anxiety symptoms (GAD ≥ 10) were found among 11% and 10% of the pregnant and breastfeeding women. The mean (±SD) PSS scores for pregnant and explore potential associations between depressive symptoms, anxiety, and stress, and women's sociodemographic, health, and reproductive characteristics. A multinational, cross-sectional, web-based study was performed in Ireland, Norway, Switzerland, the Netherlands, and the UK between 16 June and 14 July 2020. Pregnant and breastfeeding women up to 3 months postpartum who were older than 18 years were eligible to participate. Data were collected through an anonymous online survey. The survey was promoted using banners on (hospital) websites, social media accounts, and pregnancy and breastfeeding forums commonly visited by pregnant women and/ or new mothers. Information about recruitment tools used and internet penetration rates is summarized in the Supplementary material (Table S1 ). The study findings are reported according to STROBE guidelines. The survey was part of a large, multinational COVID-19 research project aimed at studying pregnant and breastfeeding women's mental health status, medication use, breastfeeding practices, access to health services, and information needs during the pandemic. This manuscript focuses on women's mental health status (see Supplementary material, Figure S1 ). Disorder seven-item scale (GAD-7), and the Perceived Stress Scale (PSS) were used to assess mental health status. Depressive symptoms were measured by the EDS, which is a self-report 10-item scale. 16, 17 Each question has four different options which are scored 0, 1, 2, or 3. The scale rates the intensity of depressive symptoms over the last 7 days. Total score ranges between 0 and 30; major depressive symptoms were defined as women having a total EDS score of ≥13, while ≥5 on the EDS anxiety subscale (EDS-3A) was considered as high risk for anxiety. 16, 18, 19 The GAD-7 is a self-report scale that assesses the level of generalized anxiety experienced over the previous 2 weeks. 20 The scale consists of seven items measuring the frequency of being bothered by specific problems on a fourpoint Likert scale ranging from not at all, several days, more than half of the days, and nearly every day (scored from 0 to 3). Total scores range between 0 and 21 with higher scores indicating more generalized anxiety. Total GAD-7 scores were categorized into minimal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) , and severe (15) (16) (17) (18) (19) (20) (21) anxiety. The PSS is a self-report scale of 10 items measuring the degree to which people perceive their lives as stressful. [21] [22] [23] Respondents are asked how often they have found their lives "unpredictable, uncon- Information on sociodemographic characteristics was collected through the survey, including country, maternal age, relationship status, professional status, highest education level, smoking in pregnancy, and breastfeeding. Highest completed educational level was categorized into low, medium, and high according to national definitions. Information on health and reproductive characteristics was also collected, including having received a test for SARS-CoV-2 and the test result, chronic somatic and mental illness, parity, planned pregnancy, gestational trimester, pregnancy follow up, breastfeeding duration, and previous breastfeeding experience. All women who completed the breastfeeding survey, including those who recently ceased breastfeeding, were grouped into the category "breastfeeding women". A chronic illness was considered a condition that already existed before pregnancy. Depression, anxiety disorders, and bipolar disorder were grouped into chronic mental illness. Women's characteristics and scores on the mental health measures were analyzed using descriptive statistics. Associations between depressive symptoms (EDS ≥ 13) and characteristics of pregnant and breastfeeding women were estimated by univariable and multivariable logistic regression, and presented as crude (cOR) and adjusted (aOR) odds ratios and 95% CI. Associations between anxiety (GAD- Online informed consent was obtained from all participants before survey initiation. Ethical approval was waived in most countries, except for Ireland (Rotunda Hospital Research Ethics Committee, REC-2020-017, 23 June 2020). All data were stored and handled anonymously. In total, 9041 women participated in the survey (ie, 3907 pregnant and 5134 breastfeeding women) (see Table 1 ). Most responses were collected from Norway (31%) and the Netherlands (29%), followed by Switzerland (19%), Ireland (18%), and the UK (3%). Overall, 91% of the postpartum women were still breastfeeding at the time of survey completion. A chronic somatic or mental illness was reported by 19% and 2% of the pregnant women, and by 16% and 1% of the breastfeeding women, respectively. Allergy birthing population data is included in the Supplementary material (Table S2 ). The observed prevalence of major depressive symptoms (EDS ≥ 13) was 15% and 13% in the pregnancy and breastfeeding cohorts, respectively. Moderate to severe generalized anxiety symptoms (GAD-7 ≥ 10) were found among 11% and 10% of the pregnant and breastfeeding women, respectively. The mean ± SD) PSS scores for pregnant and breastfeeding women were 14.1 ± 6.6 and 13.7 ± 6.6, respectively. The findings for major depressive symptoms, generalized anxiety, and stress were worse among women residing in the UK and Ireland (see Table 2 Overall, a higher likelihood of major depressive symptoms (EDS ≥ 13) was observed among pregnant and breastfeeding women who reported a chronic mental illness, smoking, and living in the UK or Ireland. Major depressive symptoms were also associated with no breastfeeding at the time of survey completion, having an unplanned pregnancy, and having a chronic somatic illness in the postpartum period (see Table 3 ). Generalized anxiety among pregnant and breastfeeding women was positively associated with having a chronic mental illness and negatively associated with being professionally active in health care (see Table 4 ). Anxiety symptoms were also more likely among pregnant women living in the UK, smoking in pregnancy, and having an unplanned pregnancy, as well as among unemployed breastfeeding women and women suffering from a chronic somatic illness in the postpartum period. Stress among pregnant and breastfeeding women was positively associated with having a chronic mental illness, having a chronic somatic illness, and living in the UK or Ireland (see Table 5 ). Likewise, stress symptoms were more likely among women smoking in pregnancy and having an unplanned pregnancy, as well as among breastfeeding women who reported being unemployed and women who were no longer breastfeeding when completing the survey. Stress among pregnant women decreased with increasing age. With regard to COVID-19, pregnant and breastfeeding women who had tested positive for SARS-CoV-2 were not more likely to have major depressive symptoms, generalized anxiety, or stress at the time of survey completion compared with women without a positive test result. Reproductive characteristics such as parity and gestational trimester were also not associated with women's mental health status. This cross-sectional, web-based study aimed to assess the mental Note: The bold numbers indicate adjusted odds ratios where the 95% confidence interval does not include 1. Abbreviations: CI, confidence interval, cOR, crude odds ratio, aOR, adjusted odds ratio; N/A, not available. a Adjusted for country, professional status, smoking in pregnancy, chronic mental illness, and planned pregnancy. The results were obtained after natural logarithmic transformation of the dependent variable and are presented on this scale. The bold numbers indicate the 95% CI of the unstandardized regression coefficients of the adjusted analyses that do not include the null. Abbreviations: B, unstandardized regression coefficient; CI, confidence interval; N/A, not available. a Adjusted for country, maternal age, professional status, smoking in pregnancy, chronic somatic and mental illness, and planned pregnancy. (14%). 14 This finding is in line with a recent Chinese study suggesting that prenatal anxiety increases with the severity of the measures imposed. 13 As illustrated by the respondents' quotations, partners were often not allowed to attend perinatal checks and the delivery. As shown previously, women described considerable psychological suffering due to the exclusion of their partners from antenatal visits and around the time of birth. 27 A recent review concluded that a lack of social and/or partner support is a risk factor for antenatal depression, 28 so future policy decisions should carefully consider the impact of infection-reducing measures on the supporting role of the partner in the perinatal period. As poor mental health can lead to adverse maternal and infant outcomes, insight into potential influencing factors is critical. Identified risk factors associated with poor mental health included: a chronic mental illness, a somatic illness in the postpartum period, smoking, an unplanned pregnancy, professional status, and living in the UK or Ireland. Having a chronic physical condition has previously been identified as a risk factor for perinatal mental illness. 29 Limited TA B L E 5 Factors associated with perceived stress (PSS) among pregnant and breastfeeding women access to health services during the pandemic may have prevented women with chronic illnesses from seeing clinicians, potentially contributing to an increased psychological burden. 30, 31 Professional status also appeared to have an impact on anxiety and stress levels. While working in health care may have protected women to some extent, being unemployed placed women at higher risk of experi- Although only a few women with confirmed COVID-19 were enrolled, no association was found between a positive test result and mental health status. It should be acknowledged, however, that the EDS and GAD-7 only collect information on depressive symptoms and anxiety experienced over the last 1-2 weeks. 16, 21 As data on the exact timing of the infection were unavailable, it is possible that the positive test occurred weeks or months ago and that mental distress had already improved or resolved. The study was performed in collaboration with several members of the European Network of Teratology Information Services. Services for encouraging teratology information centers to participating in the study. None. https://orcid.org/0000-0002-4130-5869 Estimating the effects of nonpharmaceutical interventions on COVID-19 in Europe Consequences of physical distancing emanating from the COVID-19 pandemic: an Australian perspective Maternal mental health in the time of the COVID-19 pandemic Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population World Health Organization. Maternal mental health Self-reported perinatal depressive symptoms and postnatal symptom severity after treatment with antidepressants in pregnancy: a cross-sectional study across 12 European countries using the Edinburgh Postnatal Depression Scale Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis Severe maternal morbidity and mortality associated with COVID-19: the risk should not be downplayed Coronavirus disease 2019 during pregnancy: do not underestimate the risk of maternal adverse outcomes Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: systematic review and meta-analysis Measuring stress before and during pregnancy: a review of population-based studies of obstetric outcomes Prenatal anxiety and obstetric decisions among pregnant women in Wuhan and Chongqing during the COVID-19 outbreak: a cross-sectional study Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic: a call for action Moms are not OK: COVID-19 and maternal mental health. Front Glob Women's Health Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale Validation of the Edinburgh Depression Scale during pregnancy Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data A brief measure for assessing generalized anxiety disorder: the GAD-7 A global measure of perceived stress Perceived stress and cognitive function in older adults: which aspect of perceived stress is important? The effects of perceived stress, traits, mood states, and stressful daily events on salivary cortisol A systematic review and meta-regression of the prevalence and incidence of perinatal depression A review of longitudinal studies on antenatal and postnatal depression Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis Pregnant under the pressure of a pandemic: a large-scale longitudinal survey before and during the COVID-19 outbreak Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review Chronic physical conditions and risk for perinatal mental illness: a population-based retrospective cohort study SARS-CoV-2 infections and impact of the COVID-19 pandemic in pregnancy and breastfeeding: results from an observational study in primary care in Belgium The impact of the Covid-19 lockdown on the experiences and feeding practices of new mothers in the UK: preliminary data from the COVID-19 New Mum Study European Centre for Disease Prevention and Control. Baseline projections of COVID-19 in the EU/EEA and the UK: an update 33. van Gelder MM, Bretveld RW, Roeleveld N. Web-based questionnaires: the future in epidemiology? Identifying the women at risk of antenatal anxiety and depression: a systematic review Education level and risk of postpartum depression: results from the Japan Environment and Children's Study (JECS)