Maternal Mental Health, COVID-19 Related Distress and Disruptions in Lifestyle Behaviors among Postpartum Mothers with a Previous Hypertensive Disorder of Pregnancy

Abstract

Background:

Many perinatal people experienced pandemic-related distress and changes in health behaviors at the onset of the COVID-19 pandemic, but less is known about how the pandemic continued to impact their health.

Objective:

The current study examined the influence of pandemic-related distress and maternal mental health on postpartum lifestyle behaviors of mothers with a previous hypertensive disorder of pregnancy.

Methods:

Between September 2021 and March 2022, 82 postpartum (19.2 ±5.5 months) mothers with a hypertensive disorder of pregnancy completed measures of pandemic-related distress and pandemic-related disruption in lifestyle behaviors from the Coronavirus Perinatal Experiences Impact Survey. A PHQ-9 score ≥10 and a score ≥ 3 on the Breslau scale indicated significant depressive and post-traumatic stress disorder (PTSD) symptoms, respectively.

Results:

Twenty-two (27.2%) and 30 (36.6%) participants had significant depressive or PTSD symptoms, respectively. In models adjusted for education, income, parity, delivery pre or peri pandemic, intervention group, and pre-pregnancy mental health history, both PTSD symptoms (B=0.229, p=.029) and pandemic-related distress (B=0.492, p<.001) associated with greater disruption in health behaviors. Depressive symptoms did not associate with greater disruption in health behaviors (B=0.169, p=.135).

Conclusion:

Monitoring PTSD symptoms may be vital in supporting mothers with hypertensive disorders of pregnancy in making lifestyle changes to prevent cardiovascular disease.

Hypertensive disorders of pregnancy, which include preeclampsia, gestational hypertension, eclampsia and acute on chronic hypertension, are associated with a three-fold higher risk of coronary heart disease, and stroke within the five years post-pregnancy,¹ and the elevated risk persists for decades.^2-4 Thus, hypertensive disorders of pregnancy provide important information to the mother and her healthcare team about her future cardiovascular disease (CVD) risk. Implementing lifestyle changes, such as regular physical activity and diet changes, are a key element of CVD risk reduction for young people with a history of hypertensive disorders of pregnancy, but the COVID-19 pandemic presented many challenges to making or sustaining behavioral change.

The mental health decline among perinatal women related to stress and worries about COVID-19 at the onset of the pandemic are well documented.^5-10 Many perinatal women experienced distress about the altered birthing experiences, loss of anticipated support, and concerns about their infant’s safety.^5-8 Early in the pandemic experts warned that postpartum depression and other mental health disorders would likely be more common as result of the significant disruption in daily lives and support systems.¹⁰ Reports of data collected in the first 6 months of the pandemic report nearly 40% of women screened positive for postpartum depression, compared to the typical estimates of 10-15%.^5,11 However, less is known about COVID-related distress and postpartum mental health beyond the initial months of the pandemic.

Depression and post-traumatic stress disorders are two mental health disorders that have been investigated as novel CVD risk factors.^12-15 Symptoms of postpartum depression such as depressed mood, fatigue, and changes in appetite can disrupt healthy lifestyle behaviors (e.g., exercise) that are essential for cardiovascular health. Post-traumatic stress disorder (PTSD) is another maternal mental health disorder and may co-occur with postpartum depression, but they are two distinct conditions.¹⁶

Maternal PTSD can result from experiences related to pregnancy or infant complications but can also be related to trauma that occurred prior to pregnancy. Estimates from recent systematic reviews suggest that childbirth associated PTSD occurs in nearly 1 in 5 pregnancies, with women experiencing complications, such as preeclampsia, more likely to endorse PTSD symptoms than women with uncomplicated pregnancies.^17,18 In addition, one of the few studies of PTSD specifically among perinatal people during the COVID-19 pandemic observed that a history of PTSD was associated with a 3-fold higher risk of having elevated PTSD symptoms.⁵ In general, PTSD, like other mental health conditions, increased during the COVID-19 pandemic, and adults of childbearing age were among the most impacted.^19-21

Although much of the research on postpartum mental health focuses on the impact on the infant’s development and wellbeing, a growing body of research indicates depression and PTSD as significant contributors to incident CVD.²² A recent study using claims data in Canada identified hospitalization for postpartum depression up to five years after birth was associated with a 2-3 fold higher risk of future CVD (e.g., heart failure, ischemic heart disease).¹² Similarly, PTSD among other cohorts of women (e.g., women veterans, nurses with a history of trauma) is associated with higher CVD risk, but few studies have explored this relationship in the context of childbirth-related PTSD.^14,23

Our conceptual model is synthesized from prior research documenting plausible ways stress becomes embedded within the body (figure 1).^24-26 A dysregulated immune system related to chronic stress, in this case due to the pandemic and pregnancy complications, is among the most supported models linking depression and PTSD to an increased risk of developing CVD.^26-28 Periods of high stress are associated with a decline in mental health and can lead to disruptions in sleep, diet, and other lifestyle behaviors.²⁵ These behaviors are linked to CVD through various pathways, including inflammation. Notably, the behavioral pathway has been investigated as a modifiable target that could improve inflammation and other CVD risk factors. For example, interventions have focused on physical activity and dietary changes to reduce inflammation in populations at high risk of CVD.^29,30 Primary and secondary prevention of cardiovascular disease is a priority for people with a history of preeclampsia and other hypertensive disorders of pregnancy.^2,4,31-33 Pregnancy is a window to the future cardiovascular health of the mother, and there is a growing need for interventions tailored to the needs of young mothers.

Figure 1.

Conceptual model relating hypertensive disorders of pregnancy, Covid-19 related distress, postpartum depression, and post-traumatic stress disorder with lifestyle behaviors and cardiovascular disease risk.

The convergence of pandemic related precautions that disrupted the typical support for new parents, the stress of a pregnancy complication that has significant implications for future health, and fatigue and other internalizing behavioral symptoms related to depression or PTSD may have contributed to significant disruptions in lifestyle behaviors.^5-9 Knowledge of COVID-19 related impacts on the health behaviors of people with hypertensive disorders of pregnancy is needed to support this population of new mothers better and to address their CVD risk. The current study investigated the impact of pandemic-related distress and maternal mental health on lifestyle behaviors among postpartum mothers with previous hypertensive disorders of pregnancy. We hypothesized that higher pandemic-related distress would be associated with greater disruption in healthy lifestyle behaviors. Secondly, we hypothesized that clinically significant mental health symptoms of depression or PTSD would also be associated with greater disruption in lifestyle behaviors.

Methods

Data are from 82 of 148 women with an hypertensive disorders of pregnancy and overweight/obesity enrolled in a CVD risk reduction intervention study.³⁴ Participants were recruited from the postpartum unit of a hospital in southwestern Pennsylvania or referred by community partners. Participants were randomized to a blood pressure monitoring intervention plus access to a website with resources for new moms, blood pressure monitoring, health coaching, and website resources, or the control group, which had access to the website only.³⁴ The three study arms were not significantly different on weight, BMI, or self-efficacy for healthy eating or physical activity. After the University of Pittsburgh IRB approved the COVID-19 survey, we recontacted the women between September 2021 and March 2022, when they were on average 19 months postpartum to ask about their pandemic-related experiences and current mental health. All participants were eligible for the COVID-19 survey regardless of their assigned intervention arm. The mothers who did not respond to the COVID-19 survey were not statistically different in educational attainment, income, race/ethnicity, parity, or severity of hypertensive disorders of pregnancy than the survey respondents (all p >.10).

Measures

Pandemic-related disruption in health behaviors and pandemic-related distress were measured with items from the Coronavirus Perinatal Impact Survey (COPE-IS).³⁵ The COPE-IS was among the first questionnaires designed to assess the experiences of pregnant and postpartum people during the COVID-19 pandemic.^36,37 Pandemic-related changes in lifestyle behaviors were measured with three questions about disruptions in diet, physical activity, and sleep. For example, the question about diet asked, “How has the COVID-19 outbreak changed your daily diet or nutrition?” The response scales for the three questions about diet, physical activity, and sleep are on a 4 or 5-point Likert scale. The responses were summed for a total score ranging from 5 to 14, where higher numbers represent greater disruption in health behaviors.

Pandemic-related distress was measured with two questions from the COPE-IS about change in stress levels due to the COVID-19 pandemic with a 7-point Likert response and the extent to which the pandemic had a positive or negative impact on their life using a 5-point Likert response. Both variables were recoded as 3-level variables per the COPE-IS scoring and summed for a total score ranging from 0 to 4, with higher representing more distress.

Clinically significant depressive symptoms were measured with the 9-item Patient Health Questionnaire-9 using the standard cutoff of 10 or greater.³⁸ The survey prompt instructs participants to respond based on their feelings over the last two weeks. The PHQ9 has been used with similar study populations and demonstrated acceptable reliability in our sample (Cronbach’s alpha = 0.87).³⁹ PTSD-related symptoms were measured with the 7-item Breslau Scale with a cutoff of 3 or greater indicating clinically significant symptoms. The Breslau scale screens for avoidance, numbing, or hyperarousal symptoms of PTSD. The survey prompt indicated to respond based on how they have felt since their pregnancy to assess current PTSD symptoms that could be distinct from previous ongoing trauma.⁴⁰ The Breslau has been used in other research with postpartum people and demonstrated acceptable reliability in our sample (Cronbach’s alpha = 0.69).^41,42

Self-reported characteristics include age, race/ethnicity, highest education attained, household income, marital status, parity, and pre-pregnancy history of PTSD or depression. The date of the local shut-down order (March 2020) was used to categorize delivery status as pre- or post-pandemic.

Statistical Analysis

Descriptive statistics detail the sample and the prevalence of pandemic-related distress, disruptions in health behaviors and mental health symptoms. Significant differences between the outcome and exposure variables and participant characteristics identified the following confounders to be included in the regression models: education, income, parity, intervention group, pandemic delivery status, and pre-pregnancy history of PTSD or depression. Hierarchical linear regression was conducted to assess the relationship between COVID-19 distress and disruption in health behaviors total score. We used the variance inflation factor (VIF) to detect multicollinearity.⁴³ The VIF was consistently < 2, below the threshold of 4, indicating that multicollinearity was not a concern in our model. Block one included COVID-19 distress and covariates and block two added maternal mental health symptoms using separate models for PTSD and depressive symptoms. Due to variation in the Likert scales of the lifestyle behaviors questions, the analysis was completed with the raw total score and a transformed z-score. The interpretation of the results was unchanged, so the untransformed results are reported.

Results

The table describes the sample characteristics of the 82 participants who completed the survey. The mean maternal age was 32.53 ± 5.19 (Range: 21.9 – 43.7), 20% had no post-secondary education, 83.33% were married/partnered and 55% were primiparous. Of the 82 women, 22 (27.16%) and 30 (36.59%) had clinically significant depressive or PTSD symptoms, respectively, and 17 (20.99%) had both.

In adjusted models, COVID-19 related distress was associated with greater disruption in health behaviors (B=0.590, p<.001). When PTSD symptoms were added to the model, both PTSD symptoms (B=0.229, p=.029) and COVID-19 related distress (B=0.492, p<.001) were significantly associated with greater disruption in health behaviors and the model accounted for 43% of the variance (Table 2).

Table 2.

The association of pandemic-related disruption in health behaviors with Covid-19 distress and mental health symptoms

	Characteristic	Std B	t	p-value	R2
Model 1	COVID-19 distress	.59	6.11	<.001	.39
Model 2	COVID-19 distress	.49	4.74	<.001	.43
	PTSD symptoms	.23	2.23	.029
Model 3	COVID-19 distress	.56	5.25	<.001	.37
Model 4	COVID-19 distress	.51	4.60	<.001	.36
	Depressive symptoms	.17	1.51	.135

Models 1 and 2 are adjusted for education, income, parity, intervention group, pandemic delivery status, and history of PTSD. Models 3 and 4 adjusted for education, income, parity, intervention group, pandemic delivery status, and history of depression. All analyses were conducted in SAS v9.4

In separate adjusted models examining the impact of pandemic-related distress and depressive symptoms on lifestyle behaviors, depressive symptoms were not associated with greater disruption in health behaviors (B=0.169, p=.135) independent of COVID-19 related distress (B=0.507, p<.001). None of the covariates were associated with pandemic-related disruption in health behaviors. Lastly, we conducted a sensitivity analysis by excluding participants who reported a history of pre-pregnancy depression or PTSD. The relationship between PTSD and disruption in health behaviors was attenuated slightly (B=0.220, p=.055), but the general interpretation of the findings remains unchanged (see Supplemental Table).

Discussion

Over 19 months into the pandemic, COVID-19-related distress was associated with greater disruption in health behaviors among women with hypertensive disorders of pregnancy. Clinically significant PTSD symptoms were a stronger, independent predictor of more disruption in health behaviors than depressive symptoms. Notably, most women with PTSD symptoms also had depressive symptoms, which may contribute to the robust findings for PTSD symptoms. Our findings suggest that assessing mental health symptoms among women with an hypertensive disorders of pregnancy who gave birth peri-pandemic may be important to support the uptake of guideline-recommended lifestyle behaviors for CVD risk reduction.

The results from the current study align with and extend data collected in 2020 from a UK cohort of 700 women with gestational diabetes.⁸ Pandemic-related fears were the most common reason for declines in physical activity and regular changes of pregnancy, such as declining energy.⁸ Our results provide data on the influence of pandemic distress on health behaviors of women with hypertensive disorders of pregnancy at a time when adopting a healthier lifestyle needs to be a priority.

Approximately one-third of women in our study reported symptoms of PTSD, higher than the 11% in another study with perinatal women in the U.S. earlier in the COVID-19 pandemic⁵. Review studies estimate the prevalence of postpartum PTSD among a general pregnancy population to be between 3% and 17%,^17,18 on par with the lifetime prevalence of PTSD for female veterans receiving care through the VA.^44,45 Much of the research investigating the relationship of PTSD and incident CVD was conducted among the veteran population. From that body of literature, there is evidence of associations of PTSD with greater atherosclerotic burden and ischemic coronary disease after accounting for depression and traditional risk factors.^15,46 A recent study on women veterans found the strongest relationship between PTSD and ischemic heart disease among younger women (HR 1.72, 95% CI 1.55, 1.93).¹⁴ More research is needed to understand maternal and infant factors that contribute to PTSD after a hypertensive disorder of pregnancy, determine whether to implement PTSD screening into clinical care for people with hypertensive disorders of pregnancy, identify evidence-based treatment for postpartum PTSD, and further investigate the relationship between PTSD and CVD prevention.

Strengths and limitations

A few limitations deserve mention, this is a cross-sectional analysis of data from a single site which limits generalizability and causality cannot be determined. Data on prior history of depression or PTSD were self-reported and subject to recall bias, and data on current mental health treatment is not available. Also, the current study does not include data on other relevant forms of chronic stress, such as racism and sexism. Nevertheless, our findings fill a gap in the literature about the impact of the pandemic on mental health and health behaviors in a young population of birthing people at high risk for CVD.

Conclusion

Our findings suggest that women with hypertensive disorders of pregnancy who delivered peri-pandemic experienced distress and significant mental health symptoms which disrupted their ability to engage in healthy lifestyle behaviors. Asking about pregnancy experiences and mental health symptoms for women with hypertensive disorders of pregnancy may be vital in supporting them in making lifestyle changes to prevent CVD.

As nurses and clinical team members work together to develop collaborative interventions for the primary and secondary prevention of cardiovascular disease, integrated care models should be a priority.^4,32 Researchers and practitioners can work together to identify the role of nursing in the growing field of cardio-obstetrics, especially as it relates to supporting postpartum lifestyle changes, health education, and medication adherence to reduce CVD risk.^31,33 The incidence of preeclampsia is rising, with a notable 21% increase between 2005 and 2014, and research suggests that COVID-19 may contribute to a continued rise in preeclampsia rates, and related racial disparities in CVD.^47,48 There is a growing need for innovative, tailored interventions for this young population at risk of heart disease. Integrated care models for CVD prevention will need a dual focus on mental health and cardiovascular health.

Table 1.

Sample characteristics

	N	n (%) or mean±SD
Age	82	32.5 ± 5.2
Highest Education ≤ High School	80	16 (20)
Household Income $50,000+	76	52 (68.4)
Self-reported race	82
Asian		1 (1.2)
Black		16 (19.5)
White		65 (79.3)
Marital status (Married or partnered)	78	65 (83.3)
In the control group of the parent study	82	25 (34.2)
Health Behaviors
Moderate-extreme disruption in physical activity	82	2.2 ± 1.1
Pandemic worsened sleep	82	3.3 ± 0.6
Pandemic worsened diet	79	3.4 ± 1.0
Overall pandemic disruption in health behaviors	79	8.9 ± 2.1
COVID-19
Diagnosed with COVID-19	82	15 (18.3)
Household member diagnosed with COVID-19	82	15 (18.3)
Covid-19 related distress	82	2.3 ± 1.2
Pregnancy Characteristics
Preeclampsia (mild or severe)	81	43 (53.1)
Primiparous	80	44 (55.0)
Gave birth pre-pandemic	82	50 (61.0)
Months postpartum	82	19.2 ± 5.5
Clinical Characteristics
Depression PHQ9 ≥10	81	22 (27.2)
Self-reported history of pre-pregnancy depression	82	37 (45.1)
PTSD Breslau ≥3	82	30 (36.6)
Self-reported history of pre-pregnancy PTSD	81	8 (9.9)

PTSD = Post-traumatic Stress Disorder; All analyses were conducted in SAS v9.4