Patterns of peripartum depression and anxiety during the pre-vaccine COVID-19 pandemic

BACKGROUND

Pregnant people are vulnerable to new or worsening mental health conditions. This study aims to describe prevalence and course of depression and anxiety symptoms in pregnancy during the pre-vaccine COVID-19 pandemic.

METHODS

This is a prospective cohort study of pregnant individuals with known or suspected COVID-19. Participants completed Edinburgh Postnatal Depression Scale (EPDS) and Generalized-Anxiety Disorder-7 (GAD-7) questionnaires, screening tools for depression and anxiety, at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum. Prevalence of elevated depressive and anxiety symptoms at each visit was described. Univariable logistic regression analysis was used to determine the association between demographic and clinical factors and those with elevated depression or anxiety symptoms.

RESULTS

317 participants were included. The prevalence of elevated antepartum depression symptoms was 14.6%, 10.3%, and 20.6% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. The rate of elevated anxiety symptoms was 15.1%, 10.0%, and 17.3% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. A prior history of depression and/or anxiety (p's < 0.03), as well as higher EPDS and GAD-7 scores at enrollment (p's < 0.04) associated with elevated depression and anxiety symptoms throughout pregnancy and the postpartum period. Quarantining during pregnancy was associated with elevated anxiety symptoms at 34weeks gestational age in univariate (P = 0.027) analyses. COVID-19 diagnosis and hospitalization were not associated with elevated depression or anxiety symptoms.

CONCLUSIONS

Elevated depression and anxiety symptoms were prevalent throughout pregnancy and the postpartum period, particularly in those with prior depression and/or anxiety and who quarantined. Strategies that target social isolation may mitigate potential adverse consequences for pregnant people, and continued vigilance in recognition of depression and anxiety in pregnancy should be considered.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

BACKGROUND

In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction.

METHODS

To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth.

RESULTS

Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth.

CONCLUSIONS

While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Cesarean overuse and the culture of care

OBJECTIVE

To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.

DATA SOURCES/STUDY SETTING

Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.

STUDY DESIGN

Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.

METHODS

Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.

PRINCIPAL FINDINGS

1718 respondents from 70 hospitals responded to the Labor Culture Survey. The "Unit Microculture" subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8-items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = -47 to -35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.

CONCLUSIONS

Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.