key: cord-0900413-mxb6adf9
authors: Wheeler, Jenna M.; Misra, Dawn P.; Giurgescu, Carmen
title: Stress and coping among pregnant black women during the COVID‐19 pandemic
date: 2021-04-12
journal: Public Health Nurs
DOI: 10.1111/phn.12909
sha: 5dfea7b80fb15c6b932d3aea39116bb184ac73c8
doc_id: 900413
cord_uid: mxb6adf9

OBJECTIVE: This study explored stress and coping among pregnant Black women prior to and during the COVID‐19 pandemic. DESIGN: Prospective, longitudinal, cohort study. SAMPLE: Thirty‐three women enrolled in the Biosocial Impact on Black Births study prior to the COVID‐19 pandemic and who were still pregnant during the pandemic. MEASUREMENTS: Questionnaires included the Perceived Stress Scale, Prenatal Coping Inventory, and questions related to sociodemographic characteristics, worry about COVID‐19, and coping strategies used during the pandemic. RESULTS: Women reported very much being worried about my child getting COVID‐19 (46%) and my family member getting COVID‐19 (46%). Women reported specific active coping strategies very much reduced their feelings of discomfort during COVID‐19: God, religion, or spirituality (24%), social media (24%), and following government advice (24%). Higher use of avoidance coping prior to the pandemic was associated with higher levels of stress both prior to (r = 0.60, p < .001) and during (r = 0.47, p < .01) the pandemic. CONCLUSION: Women reported worries about COVID‐19 and used various strategies to cope with feelings of discomfort due to the pandemic. Nurses should assess the stress level of pregnant Black women and recommend active coping strategies during the pandemic.

ducted with women who were pregnant during Hurricane Katrina or became pregnant immediately after the hurricane, behavioral disengagement as a coping strategy was associated with more symptoms of depression among women who perceived more stress (Oni et al., 2012) . In contrast, effective coping strategies such as optimism and resilience reduced levels of psychological distress among a diverse group of pregnant women, albeit not specifically demonstrated for Black women (McNamara et al., 2018) . While the body of literature related to pregnancy, racial disparities, and stress during COVID-19 is growing, there are no studies specific to coping strategies used during the COVID-19 pandemic. It is important to understand the impact coping may have on high-risk populations. To our knowledge, this study is the first to explore the coping strategies, perceived stress, and worries of pregnant Black women during the COVID-19 pandemic.

The Biosocial Impact on Black Births (BIBB) study is a prospective, longitudinal, cohort study that examines the role of maternal and psychosocial factors on birth outcomes among Black women across pregnancy. Women were enrolled into the BIBB study if they were Black or African American, were 18-45 years of age, had singleton pregnancies, and were 8-29 weeks gestation. A small, homogenous, convenience sample of 66 women who participated in the BIBB study and were still pregnant in May-June 2020 were invited to participate in a survey focused on women's experiences during the COVID-19 pandemic. A final sample of 33 women who participated in the BIBB study completed the COVID-19 survey during their pregnancy.

Characteristics (e.g., maternal age, levels of education, employment) were collected by self-reported survey data as part of the BIBB study. As part of the COVID-19 survey, women were asked questions about the symptoms of SARS-CoV-2 (the virus that causes COVID-19) including fever, cough, shortness of breath, runny nose, muscle pain, sore throat, and headache (1 = yes and 0 = no). Women were also asked if they were tested for COVID-19, how many times they were tested, the results of the test, any hospitalization for COVID-19, and about family members and friends who tested positive for COVID-19.

The Cohen's Perceived Stress Scale (PSS) asks about feelings and thoughts during the prior month (e.g., felt upset, stressed out). The instrument contains 10 items on a 5-point scale (0 = never to 4 = very often) with a total score ranging from 0 to 40. Higher scores represent higher levels of perceived stress. In the current study, Cronbach's α was 0.91 for the BIBB study and 0.92 for the COVID-19 study.

The Prenatal Coping Inventory (PCI), administered as part of the BIBB study, contains 22 items with four coping style subscales:

Preparation for motherhood (8 items, range 0-32), Avoidance (7 items, range 0-28), Positive interpretation of events (5 items, range 0-20), and Prayer (2 items, range 0-8). The subscales are scored on a 5-point scale (0 = never to 4 = almost always). Higher scores for each subscale represent higher use of that coping strategy. The Cronbach's α for the subscales of the BIBB study were as follows:

Preparation for motherhood (0.82), Avoidance (0.73), Positive interpretation of events (0.67), and Prayer (0.90).

Women completed four questions related to worry about COVID-19 

Women also answered questions about specific coping strategies used during the COVID-19 pandemic (e.g., phone calls; social media; video games; religion; information from the government) on a 4-point scale (1 = not at all to 4 = very much) as part of the COVID-19 survey.

Higher scores represent increased use of that coping strategy.

The BIBB study was approved by the Institutional Review Board (IRB) at the participating universities and clinical sites in the Midwest of the United States. Women participated in the BIBB study after obtaining informed consent. Prior to the pandemic, participants completed an online questionnaire using Qualtrics on a tablet provided by research staff. The questionnaire included sociodemographic characteristics, the PSS, and the PCI. As part of the consent process, women opted to be contacted for additional studies. The BIBB study was amended to IRB at the participating sites to conduct the COVID-19 survey. A convenience sample of 66 women who participated in the BIBB study and were still pregnant in May-June 2020 were contacted online by the research staff and invited to participate in the COVID-19 survey about women's experiences during the COVID-19 pandemic. Thirty-three women (50% response rate) completed the online questionnaire. The research staff sent up to two reminders three days apart for women who did not complete the questionnaire. The 33 women completed the BIBB survey between December 16, 2019-March 13, 2020, and the COVID-19 survey between May 21 and June 23, 2020. The COVID-19 survey included sociodemographic characteristics related to COVID-19, the PSS, worry about COVID-19, and coping strategies specific to COVID-19, but did not include the PCI. Women received a $30 store gift card for completing the BIBB questionnaire and a $20 store gift card for completing the COVID-19 questionnaire.

IBM SPSS 25 was used for all analyses. Descriptive statistics (e.g., mean, standard deviation) were used to describe sample characteristics and major variables of the study (e.g., perceived stress, coping).

Pearson's r correlation coefficient analyses were used to examine relationships among variables.

A final sample of 33 women participated in the BIBB study and completed the COVID-19 survey. The mean age of women was 28.6 ± 4.8 years (range 20-39). The mean gestational age at the time of the completion of the BIBB survey was 13.3 ± 3.8 weeks (range 8-24 weeks) and the mean gestational age at the time of the completion of the COVID-19 survey was 32.0 ± 3.4 weeks (range 24-38 weeks; see Table 1 ).

Of the 33 women responding to the COVID-19 survey, symptoms were reported as follows: one woman had fever, one woman had shortness of breath, three women had headache, and one woman was unsure if her symptoms were related to COVID-19. Only three women were tested for SARS-CoV-2 (COVID-19) and all reported negative results. Five women indicated that one of their family members had tested positive for COVID-19, but only one of these women lived in the same household as the infected family member. Two women indicated that a friend had tested positive for COVID-19. , and myself getting COVID-19 (36%) though a few women were not worried at all (see Table 2 ).

The mean scores for the subscales of the PCI in the BIBB survey are presented in Table 1 . Women reported high use of prayer and moderate use of avoidance, preparation for motherhood, and positive interpretation of events prior to the pandemic. While we did not repeat the PCI scale in the COVID-19 survey, we directly queried women about a range of coping strategies to address COVID-19.

A variety of coping strategies were utilized by the women in this study during the COVID-19 pandemic. Women reported the following coping strategies very much reduced their feelings of discomfort during COVID-19: God, religion, or spirituality (24%), social media (24%), following the government's advice (24%), making time to relax (21%), and phone or video calls with friends and family (21%). These strategies were reported not at all helpful in reducing their feelings of discomfort: Video games (63.6%), my work (42.4%), and information from the government (30.3%; see Table 3 ).

Higher use of avoidance coping prior to the COVID-19 pandemic was associated with higher levels of perceived stress both prior to (r = 0.599, p < .001) and during (r = 0.474, p < .01) the pandemic.

Higher use of positive interpretation of events coping prior to the pandemic was associated with lower levels of perceived stress prior to the pandemic (r= 0.568, p < .01). The association between positive interpretation of events coping prior to the pandemic and perceived stress during the pandemic was not significant. Preparation for motherhood coping and prayer coping strategies were not related to perceived stress prior to the pandemic or during the pandemic (see Table 4 ). Our results suggest that social support from friends and family (even though physically distanced) specifically eased feelings of discomfort and worry among pregnant Black women during the early pandemic. This is consistent with research prior to the pandemic finding that pregnant Black women who reported higher levels of social support also reported lower levels of psychological distress (Giurgescu et al., 2015) . Beyond social support, pregnant women in our cohort used various active coping strategies to deal with their feelings during the COVID-19 pandemic. Prayer and spirituality, used by many women in our study, was also an active coping strategy frequently reported among Black women prior to the pandemic (Ruiz et al., 2015) . In contrast, avoidance coping has been related to anxiety, Ibrahim et al., 2019; Ruiz et al., 2015) . In our study, women who reported higher use of avoidance coping prior to the pandemic were more likely to report higher levels of perceived stress both prior to the pandemic and during the pandemic. These findings suggest a range of coping strategies were utilized by pregnant Black women both prior to and during the COVID-19 pandemic; however, active coping strategies may provide increased benefit among this population.

It is imperative to note that the pandemic was not the only major upheaval occurring in the United States during May and June 2020. 

Although the BIBB study laid a strong foundation for the current study, only a small homogenous, convenience sample of women was still pregnant during the COVID-19 pandemic and eligible to complete the COVID-19 survey. The small final sample size (N = 33) of women from the Midwest, U.S. limits the ability to generalize results Nurses should also consider the impact communication of information may have among this population. Many women in this study reported using social media and that information, actions, and advice of the government were both helpful and not helpful in reducing the feelings of discomfort (see Table 3 ). Public health nurses may consider utilizing social media to spread best practices related to infection prevention, mental health, and coping strategies as an essential nursing intervention. Ensuring clear, concise communication in a relevant, meaningful way may improve the dissemination and application of health information among pregnant Black women, particularly during the COVID-19 pandemic.

The COVID-19 pandemic has impacted the lives of people all over the world. Dissemination of health information, isolation from others, and uncertainty of long-term outcomes may contribute to increased psychological distress. Much is still unknown about the effects of COVID-19 among pregnant woman, but the health disparities among Black Americans is evident. This study addresses a gap in the literature regarding the experiences of stress, worry, and coping among pregnant Black women during the COVID-19

pandemic.

Pregnant Black women in our Midwest U.S. sample reported moderate levels of perceived stress both prior to and during the pandemic, reported feelings of worry related to COVID-19 infection, and reported various coping strategies utilized to reduce feelings of discomfort. Higher use of positive interpretation of events coping prior to the pandemic was associated with lower levels of perceived stress prior to the pandemic but not during the pandemic. Higher use of avoidance coping prior to the pandemic was associated with higher levels of stress both prior to and during the pandemic.

Nurses must understand the disproportionate effect that maternal stress during COVID-19 may have on pregnant Black women and be aware of effective coping strategies. Appropriate assessment, intervention, and education of patients and members of this community are imperative to address these disparities. Public health and maternal-child nurses alike should ensure clear communication of government-mandated and scientifically supported best practices, particularly during the COVID-19 pandemic.

This study was funded by the National Institutes of Health, National

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Stress and coping among pregnant black women during the COVID-19 pandemic

Institute of Minority Health and Health Disparities, NIH Grant # R01MD011575. We have no known conflicts of interest to disclose.We would like to acknowledge all the women who participated in this study.

Research data are not shared at this time.

https://orcid.org/0000-0002-8035-1753Carmen Giurgescu https://orcid.org/0000-0002-4577-3184