Common model of stress, anxiety, and depressive symptoms in pregnant women from seven high-income Western countries at the COVID-19 pandemic onset

Risk factors associated with postpartum anxiety in Australia, Europe, and North America: A systematic review and narrative synthesis

BACKGROUND

Reducing the prevalence and consequences of anxiety following childbirth (postpartum anxiety) is a strategic priority in the UK and many similar nations; a comprehensive review of risk factors can support the development of interventions and guide further research.

METHODS

This registered systematic review was guided by 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) and analysed using 'Synthesis Without Meta-analysis' (SWiM) to answer the question; 'What factors have been reported to increase the risk of maternal postpartum anxiety (PPA) in Australia, Europe, and North America?'. MEDLINE and PsycINFO were searched for relevant research from Australia, Europe, and North America, published up to July 2021.

RESULTS

Screening yielded 39 reports (total N = 40,238). Seven risk categories were identified (Psychopathology and personality, Social, Socio-demographic, Health, Cognitive, Pregnancy and birth, and Infant characteristics and postpartum experiences). Historic and concurrent depression, historic anxiety, and low social support were the most frequently evidenced risk factors.

LIMITATIONS

The review was limited to three geographical regions with comparable health, political, and cultural contexts, and research pertaining only to special populations was excluded.

CONCLUSIONS

Findings synthesise new evidence of the risk factors associated with PPA, whilst the discussion highlights potentially modifiable factors as targets for intervention. Monitoring for risk factors during routine pregnancy and postpartum care would allow for additional surveillance and earlier intervention with those most at risk. Peer support should be offered to people with heightened vulnerability to PPA. Developing support strategies that address cognitive vulnerabilities (e.g., parenting-related confidence) could prove particularly beneficial.

The efficacy of psychological interventions on well-being during the perinatal period: A systematic review

Although research has already shown the importance of promoting well-being during pregnancy and after birth, previous meta-analyses on the effectiveness of psychological interventions do not include wellbeing as a primary outcome measure, focusing instead on assessing the effectiveness in reducing symptoms. This study aimed at conducting a systematic review of the effects of psychological interventions on well-being during the perinatal period. A search was conducted in Psycinfo, PubMed, Web of Science (WOS) and Scopus for articles published from 2014 to 2024. A review of 16 randomized clinical trials revealed that most interventions were effective in both improving well-being and reducing clinical symptoms. Face-to-face, therapist-led, and group-based approaches showed better adherence. Positive changes in well-being were maintained over time, although the postpartum transition may have influenced the maintenance of results. This study highlights the importance of including well-being measures in clinical trials during the perinatal period and advocates for a shift toward promoting well-being alongside symptom management.

Assessment of pandemic-related pregnancy stress from seven western countries using Rasch analyses

INTRODUCTION

This study examined psychometric properties of the Pandemic-Related Pregnancy Stress Scale (PREPS) using a Rasch Model (RM) in a large sample of pregnant women from Germany, Israel, Italy, Poland, Spain, Switzerland and the United States of America (USA).

MATERIAL AND METHODS

Rasch analyses were used to analyze a sample of 7185 pregnant women who completed the PREPS during the COVID-19 pandemic onset from April to August 2020. Psychological, sociodemographic, and obstetric factors were also collected and analyzed.

RESULTS

12-item and 15-item PREPS versions showed acceptable fit indices. The separation index for persons on both versions allows to distinguish more than two levels of performance and for items (high and low performers). For items, it was above 30 and the strata value for items was above 45. The category probability curves for the 12-item version showed that threshold parameter categories showed a coherent order with the meaning of the response options. However, this did not occur in the 15-item version. The item-person map showed that each item is represented by an equal length of the segment, and its threshold parameters differ only in the stress severity values. Also, there is an overlap of items. Finally, DIF analysis showed many CC-rated items as well as many items with a BB rating could be revised.

CONCLUSIONS

The implications of this psychometric study lie in the importance of having accurate measures of the stress that pregnant women in various parts of the world have experienced due to the COVID-19 pandemic.

Associations of Maternal Salivary Cortisol and Psychological Symptoms With Human Milk's Microbiome Composition

OBJECTIVE

Human milk (HM) is considered the best source of infant nutrition with many benefits for the infant. However, pregnancy changes can lead to increased stress in some women, which might affect HM composition. Although studies have demonstrated a link between maternal psychopathology and child development, it remains unclear how maternal psychobiological changes can be intergenerationally transmitted. We aimed to investigate the associations of maternal stress, depressive symptoms, and anxiety symptoms with the HM microbiome; to analyze these parameters in relation to HM glucocorticoid concentrations; and to explore the influence of HM glucocorticoids on HM bacterial composition.

METHODS

One hundred women completed psychological questionnaires (e.g., EPDS, STAI, GAS) at 34-36 weeks' gestation and in the early postpartum period and provided saliva at 34-36 and 38 weeks' gestation. HM samples were collected in the early postpartum. Microbiota were analyzed using 16S rRNA amplicon sequencing.

RESULTS

Birth anxiety was negatively correlated with Alphaproteobacteria (τ = -0.20, FDR = 0.01), whereas in the postpartum period, anxiety symptoms were negatively correlated with different taxa. The sum of postpartum-related symptoms was linked to lower Propionibacteriales. Salivary cortisol AUCg at 34-36 weeks was negatively correlated with Stenotrophomonas (τ = -0.24, FDR = 0.05), whereas HM cortisol was positively correlated with Streptococcus mitis (τ = 0.26, FDR = 0.03) and Gemella haemolysans (τ = 0.24, FDR = 0.02). No associations emerged between psychobiological parameters and HM glucocorticoids.

CONCLUSIONS

Higher perinatal psychological symptoms and prenatal salivary cortisol AUCg were associated with lower relative abundances of different bacteria, whereas higher HM cortisol was linked to higher Gemella and Streptococcus. These findings suggest a negative association between high maternal psychobiological symptoms and relative abundances of the milk microbiota.

The pandemic preterm paradox: a test of competing explanations

Epidemiologists have long argued that side effects of the stress response include preterm birth. Research reports that fear of lethal infection stressed pregnant persons at the outset of the coronavirus disease (COVID-19) pandemic and that "shutdowns" and "social distancing" impeded access to social support and prenatal care. The decline in preterm births in high-income countries, including the United States, during the early months of the pandemic therefore poses a paradox for science. Explanations of this "pandemic preterm paradox" remain untested. We applied time-series modeling to data describing 80 monthly conception cohorts begun in the United States from July 2013 through February 2020 to determine which of 3 explanations most parsimoniously explained the paradox. We infer that "prior loss," or the argument that an increase in spontaneous abortions and stillbirths depleted the population of fetuses at risk of preterm birth, best explains data currently available. We describe the implications of these results for public health practice.

Obsessive-compulsive symptom trajectories from pregnancy through the postpartum: examining longitudinal course and risk factors during the COVID-19 pandemic

PURPOSE

The peripartum is a time of increased risk for the development or worsening of obsessive-compulsive (OC) symptoms. Existing evidence suggests that OC symptoms commonly surge immediately postpartum followed by a gradual recovery. Yet how societal conditions, such as a widespread public health crisis, may affect this pattern remains unknown. Increased OC symptom prevalence in the general population during the COVID-19 pandemic coupled with the pre-existing vulnerability of peripartum women suggests they may have been at particularly high risk for sustained symptoms. Thus, the aim of the current study was to examine trajectories in OC symptoms, particularly contamination concerns, in women who gave birth during the COVID-19 pandemic, and to look at risk and resiliency factors that may influence symptom course METHODS: A sample of 164 US pregnant women were recruited during the COVID-19 pandemic. They reported OC symptoms at 3 timepoints: April/May, 2020, July, 2020, and February, 2022. We used a growth mixture modeling approach to examine OC symptom trajectories from pregnancy through the postpartum across these timepoints, comparing the goodness of fit of models with 1-5 trajectory classes for overall OC symptoms and for contamination-related OC symptoms.

RESULTS

For total OC symptoms, two classes of trajectories were identified: recovering (29.27%) versus stable low (70.73%) symptoms; for contamination symptoms alone, a subset of total symptoms, three trajectories were identified: recovering (8.54%), stable low symptoms (68.29%), and stable high symptoms (23.17%). Peripartum stress, but not sociodemographic or obstetric factors, predicted class membership.

CONCLUSIONS

These findings suggest that peripartum OC symptoms, particularly related to contamination, may persist beyond the postpartum period in some women, particularly for women exposed to elevated stress in pregnancy and the postpartum.

Social support buffers the impact of pregnancy stress on perceptions of parent-infant closeness during the COVID-19 pandemic

Pregnant individuals and parents have experienced elevated mental health problems and stress during COVID-19. Stress during pregnancy can be harmful to the fetus and detrimental to the parent-child relationship. However, social support is known to act as a protective factor, buffering against the adverse effects of stress. The present study examined whether (1) prenatal stress during COVID-19 was associated with parent-infant closeness at 6 months postpartum, and (2) social support moderated the effect of prenatal stress on the parent-infant relationship. In total, 181 participants completed questionnaires during pregnancy and at 6 months postpartum. A hierarchical linear regression analysis was conducted to assess whether social support moderated the effect of stress during pregnancy on parent-infant closeness at 6 months postpartum. Results indicated a significant interaction between prenatal stress and social support on parents' perceptions of closeness with their infants at 6 months postpartum (β = .805, p = .029); parents who experienced high prenatal stress with high social support reported greater parent-infant closeness, compared to those who reported high levels of stress and low social support. Findings underscore the importance of social support in protecting the parent-infant relationship, particularly in times of high stress, such as during the COVID-19 pandemic.

Community Members' Perceptions of a Resource-Rich Well-Being Website in California During the COVID-19 Pandemic: Qualitative Thematic Analysis

BACKGROUND

To address needs for emotional well-being resources for Californians during the COVID-19 pandemic, the Together for Wellness/Juntos por Nuestro Bienestar (T4W/Juntos) website was developed in collaboration with multiple community partners across California, funded by the California Department of Health Care Services Behavioral Health Division federal emergency response.

OBJECTIVE

This qualitative study was designed to explore and describe the perspectives of participants affiliated with California organizations on the T4W/Juntos website, understand their needs for web-based emotional health resources, and inform iterative website development.

METHODS

After providing informed consent and reviewing the website, telephone interviews were conducted with 29 participants (n=21, 72% in English and n=8, 28% in Spanish) recruited by partnering community agencies (October 2021-February 2022). A 6-phase thematic analysis was conducted, enhanced using grounded theory techniques. The investigators wrote reflexive memos and performed line-by-line coding of 12 transcripts. Comparative analyses led to the identification of 15 overarching codes. The ATLAS.ti Web software (ATLAS.ti Scientific Software Development GmbH) was used to mark all 29 transcripts using these codes. After examining the data grouped by codes, comparative analyses led to the identification of main themes, each with a central organizing concept.

RESULTS

Four main themes were identified: (1) having to change my coping due to the pandemic, (2) confronting a context of shifting perceptions of mental health stigma among diverse groups, (3) "Feels like home"-experiencing a sense of inclusivity and belonging in T4W/Juntos, and (4) "It's a one-stop-shop"-judging T4W/Juntos to be a desirable and useful website. Overall, the T4W/Juntos website communicated support and community to this sample during the pandemic. Participants shared suggestions for website improvement, including adding a back button and a drop-down menu to improve functionality as well as resources tailored to the needs of groups such as older adults; adolescents; the lesbian, gay, bisexual, transgender, and queer community; police officers; and veterans.

CONCLUSIONS

The qualitative findings from telephone interviews with this sample of community members and service providers in California suggest that, during the COVID-19 pandemic, the T4W/Juntos website was well received as a useful, accessible tool, with some concerns noted such as language sometimes being too "professional" or "clinical." The look, feel, and content of the website were described as welcoming due to pictures, animations, and videos that showcased resources in a personal, colorful, and inviting way. Furthermore, the content was perceived as lacking the stigma typically attached to mental health, reflecting the commitment of the T4W/Juntos team. Unique features and diverse resources, including multiple languages, made the T4W/Juntos website a valuable resource, potentially informing dissemination. Future efforts to develop mental health websites should consider engaging a diverse sample of potential users to understand how to tailor messages to specific communities and help reduce stigma.

Quantifying the benefits of healthy lifestyle behaviors and emotional expressivity in lowering the risk of COVID-19 infection: a national survey of Chinese population

BACKGROUND

COVID-19 is still prevalent in most countries around the world at the low level. Residents' lifestyle behaviors and emotions are critical to prevent COVID-19 and keep healthy, but there is lacking of confirmative evidence on how residents' lifestyle behaviors and emotional expressivity affected COVID-19 infection.

METHODS

Baseline study was conducted in August 2022 and follow-up study was conducted in February 2023. Baseline survey collected information on residents' basic information, as well as their lifestyle behaviors and emotions. Follow-up study was carried out to gather data on COVID-19 infection condition. Binary logistic regression was utilized to identify factors that may influence COVID-19 infection. Attributable risk (AR) was computed to determine the proportion of unhealthy lifestyle behaviors and emotional factors that could be attributed to COVID-19 infection. Sensitivity analysis was performed to test the robustness of the results.

RESULTS

A total of 5776 participants (46.57% males) were included in this study, yielding an overall COVID-19 infection rate of 54.8% (95%CI: 53.5 - 56.0%). The findings revealed that higher stress levels [aOR = 1.027 (95%CI; 1.005-1.050)] and lower frequency in wearing masks, washing hands, and keeping distance [aOR = 1.615 (95%CI; 1.087-2.401)], were positively associated with an increased likelihood of COVID-19 infection (all P < 0.05). If these associations were causal, 8.1% of COVID-19 infection would have been prevented if all participants had normal stress levels [Attributable Risk Percentage: 8.1% (95%CI: 5.9-10.3%)]. A significant interaction effect between stress and the frequency in wearing masks, washing hands, and keeping distance on COVID-19 infection was observed (β = 0.006, P < 0.001), which also was independent factor of COVID-19 infection.

CONCLUSIONS

The overall COVID-19 infection rate among residents is at a medium level. Residents' increasing stress and decreasing frequency in wearing masks and washing hands and keeping distance contribute to increasing risk of infection, residents should increase the frequency of mask-wearing, practice hand hygiene, keep safe distance from others, ensure stable emotional state, minimize psychological stress, providing evidence support for future responses to emerging infectious diseases.

Investigating Factors Influencing Prenatal Stress, Anxiety, and Fear of Childbirth During the COVID-19 Pandemic in Germany and Switzerland: An Online Survey

OBJECTIVES

Pregnant women are likely to experience high levels of stress during the COVID-19 pandemic. However, the factors that might influence the extent of experienced emotional distress are poorly understood. Therefore, we aimed to investigate potential correlates of prenatal emotional distress during the COVID-19 pandemic.

METHODS

In total, N = 1437 pregnant women from Germany and Switzerland participated in an online study during the first wave of the COVID-19 pandemic (May-August 2020). The survey assessed prenatal distress, pandemic-related pregnancy stress, general anxiety, fear of childbirth, and several socio-demographic, pregnancy- and COVID-19-related factors. Linear multivariate regression models were the main analytical strategy.

RESULTS

The results highlight that several factors such as full-time employment, nulliparity, high-risk pregnancy, emotional problems, cancelled prenatal appointments, and stating that COVID-19 affected the choice of birth mode were significantly associated with elevated prenatal distress, anxiety, pandemic-related pregnancy stress, and fear of childbirth. Conversely, access to an outdoor space was a protective factor for pandemic-related pregnancy stress and prenatal distress.

CONCLUSIONS FOR PRACTICE

Overall, the study highlights significant correlates influencing the levels of emotional distress pregnant women experienced during the COVID-19 pandemic. These findings may contribute to the improvement of maternal prenatal medical and psychological care during a public health crisis of international concern, such as the COVID-19 pandemic.

Social distancing and mental health among pregnant women during the coronavirus pandemic

BACKGROUND

The effect of social distancing due to the COVID-19 pandemic on the mental health of pregnant women is of particular concern, given potential effects on physical health, family functioning, and child development.

METHODS

Pregnant women were recruited for the "Implications of and Experiences Surrounding being Pregnant during the COVID-19 Pandemic" study at Woman's Hospital in Baton Rouge, Louisiana. Participants enrolled at any point during their pregnancy and surveys were delivered weekly until the participant indicated that she had delivered her baby; a postpartum survey followed four weeks after delivery. This analysis includes 1037 participants with baseline, 596 with follow-up, and 302 with postpartum surveys. Questions on social distancing behaviors were asked at baseline and grouped based on whether they involved social distancing from work, friends and family, or public places. Symptoms of anxiety, stress, depression, and pregnancy-related anxiety were measured. Each type of social distancing was examined as a predictor of mental health using linear model with control for confounders.

RESULTS

The study population was largely white (84.1%), married (81.8%), and educated (76.2% with a bachelor's or higher degree). Women who were younger, Black, unmarried, or had less education or income reported fewer social distancing behaviors. Mean anxiety score in the highest quartile of overall social distancing was 8.3 (SD 5.6), while in the lowest quartile it was 6.0 (SD 5.0) (p < 0.01), while perceived stress postpartum and pregnancy-related stress were not associated with social distancing. Associations were substantially diminished when controlled for baseline levels of anxiety symptoms.

CONCLUSIONS

Greater social distancing was associated with more anxiety symptoms, but worse mental health, particularly anxiety, may also have contributed to greater social distancing behaviors.

Psychometric properties of the Greek versions of the Pandemic-Related Pregnancy Stress Scale and the Pandemic-Related Postpartum Stress Scale and associated risk factors during the second year of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has affected perinatal mental health. Reliable tools are needed to assess perinatal stress during pandemic situations.

AIMS

To assess the psychometric properties of the Greek versions of the Pandemic-Related Pregnancy Stress Scale (PREPS) and the Pandemic-Related Postpartum Stress Scale (PREPS-PP) and to explore the associations between women's characteristics and perinatal stress during the second pandemic wave.

METHODS

The PREPS and PREPS-PP were completed by 264 pregnant and 188 postpartum women, respectively, who also completed the State-Trait Anxiety Inventory (STAI) and the Edinburgh Perinatal Depression Scale (EPDS).

RESULTS

The internal consistency was similar for PREPS and PREPS-PP. It was good for preparedness stress (a = 0.77 and α = 0.71, respectively) and infection stress (α = 0.83 for both scales) but low for positive appraisal (α = 0.46 and α = 0.41, respectively). Of the pregnant women, 55.33% and 55.27%, respectively, reported scores of ≥40 on STAI-S and STAI-T, and the respective percentages for the postpartum women were 47.34% and 46.80%. In addition, 14.39% of the pregnant women and 20.74% of the postpartum women scored ≥13 on the EPDS. Higher preparedness stress on PREPS and PREPS-PP was associated with primiparity (P = 0.022 and P = 0.021, respectively) and disrupted perinatal care (P = 0.069 and P = 0.007, respectively). In postpartum women, higher infection stress was associated with chronic disease (P = 0.037), primiparity (P = 0.02) and perceived risk of infection (P = 0.065). Higher score on infection stress was associated with disrupted perinatal care in both groups (P = 0.107 and P = 0.010, respectively).

CONCLUSIONS

The Greek versions of PREPS and PREPS-PP are valid tools for the assessment of women at risk of perinatal stress during a health crisis.