The Impact of the COVID-19 Pandemic on Pregnancy, Birth Experiences, and Mental Health: Voices from Women in Puerto Rico

Abstract

Objectives

The specific aims of the project are: (1) Examine the impact of COVID-19 on pregnancy experiences and outcomes; (2) Examine the mental health impact of COVID-19 in pregnant women and mothers of children 12 months or younger; (3) Identify risk and protective factors among this population in Puerto Rico.

Methods

Participants were recruited from the Puerto Rico Team for Exploring Contamination Threats (PROTECT) Superfund Program, which is composed of pregnant women and mothers from the northern karst region of Puerto Rico. The research had a mixed methods approach with a quantitative survey (n = 184) and qualitative interviews (n = 10); data collection was done in virtual mode.

Results

Findings from the qualitative interviews highlight the experiences regarding access to healthcare services, pregnancy and birth experiences, social support, and mental health during the pandemic among women with young children. These narratives serve to illustrate the particular challenges and opportunities that the participants faced during the year 2021 in regard to maternal health in Puerto Rico.

Conclusions for Practice

COVID-19 restrictions impacted the experiences in receiving healthcare services, particularly regarding the birthing process and the participants’ mental health. Social support, particularly from family, was found to be a protective factor for facing the challenges during pandemic times. We expect that the findings can lead to the development of interventions for community health centers, prenatal clinics, non-governmental organizations, and parents/caretakers in Puerto Rico.

Significance

What is already known about the subject?

What this study adds?

The COVID-19 pandemic restrictions affected access to healthcare and social support. This had a negative impact on the general population but more so for vulnerabilized sectors like pregnant and post-partum women.

This study provides insight into the experiences of pregnant and post-partum women in Puerto Rico during COVID-19. Through their narratives, we can explore how COVID-19 pandemic restrictions affected their birthing and childcare process. We can also observe the influence of social isolation on maternal mental health and how social support can be considered a protective factor.

Introduction

The COVID-19 pandemic has impacted everyone; however, certain populations have experienced greater burden and disparities than others. One of these groups is pregnant and post-partum women. This inequality is partly due to the several immunological and physiological changes that occur during pregnancy (CDC, 2019). Pregnant women are at greater risk for influenza-associated illnesses and death (Wenham et al., 2020). Historical data from previous pandemics indicate an excess of deaths among pregnant women as well as an increased risk of premature delivery and stillbirth (Elliot, 2010). However, there are also socioeconomic factors to consider, like how women are more likely to be exposed to COVID-19. For example, due to their significant presence as frontline healthcare workers and in other essential jobs, their role as family caregivers, and the greater likelihood of living in conditions of poverty (Rasmussen et al., 2008; Wenham et al., 2020).

According to the Centers for Disease and Control (CDC), disasters and public health emergencies (i.e. hurricanes, pandemics) can present unique challenges to pregnant women and mothers of young children (CDC, 2019). The World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), and United Nations Population Fund (UNFPA) have noted that the COVID-19 outbreak has put stress on healthcare systems. This stress led to the diversion of resources, reorganization of services, that have created financial and physical barriers, resulting in difficulty accessing sexual, reproductive, and maternal health services (WHO, UNFPA, UNICEF, 2020). Pandemic outbreaks can generate feelings of fear, uncertainty, and anxiety among the general population. Studies showed that mental health care was urgently needed during the current COVID-19 pandemic. For example, people may experience fear of the consequences of being infected with a potentially fatal new virus; healthcare professionals are exposed to extraordinary stress, and people in quarantine or practicing physical distancing may experience loneliness, anger, and boredom (Xiang et al., 2020).

In regard to pregnant and post-partum women, restrictions related to the birthing process have affected the quality of maternal and newborn care and have had a negative impact on their mental health (Kotlar et al., 2021; Chrzan-Dętkos et al., 2021; Lazzerini et al., 2022). In the United States a cross-sectional analysis study with postpartum women (N = 506), indicated that not having a person during birth was not associated with mental health symptoms. However, those women who indicated other changes in the birthing experience had higher levels of PTSD symptoms. These changes indicated by participants included responses related to hospital guidelines that limited or prohibited visitors after delivery and also limited hospital personnel during labor and delivery (Liu et al., 2021).

In Puerto Rico, recommendations (i.e., separation of baby and mother after birth and limitation of people in the delivery room) were placed to prevent contagion in case of positive or suspected cases but were used in general practice by the healthcare system (Rivera Orraca et al., 2021). The Puerto Rico Medical Task Force (2020) provided a series of recommendations, based on existing guidelines from the Centers for Disease Control and the World Health Organization, including temporal separation from the baby if the mother is suspected or confirmed to have COVID-19 and limiting the number of birthing companions should be discussed previously as part of the birthing plan. The Task Force emphasizes the responsibility of the health system to inform clearly and compassionately about the risks regarding transmissions and the steps required for prevention.

A study conducted in Puerto Rico indicated the prevalence of moderate to severe risk of depression was 14%, while 17% showed clinical signs of anxiety among perinatal women. The most common stressors reported were concerns about social impact and the quarantine mandate. Additionally, the sample reported concerns about the impact the pandemic would have on future employment and finances (Rodríguez Reynaldo et al., 2023). However, another study in Puerto Rico, indicated that women in postpartum did not report the Covid-19 pandemic as a significant stressor and they were able to maintain daily activities. Between 23% and 50% of women surveyed (N = 47) expressed feelings of loneliness and sadness, as well as worry, fear, and insecurity about the future. However, 80% indicated that their mental health state was not influenced by Covid-19. The authors indicate the possibility of the cumulative impact of repeated adversity (hurricanes, earthquakes) on maternal mental health in Puerto Rico and this is an aspect that should be studied in further detail (González-Barrios et al., 2024).

To better understand the impact of the COVID-19 pandemic on pregnant and post-partum women from Puerto Rico, we conducted a research project to gather information through individual semi-structured interviews. The specific aims of this study were to (1) examine the impact of the COVID-19 outbreak on pregnancy-related experiences and outcomes, and (2) examine the mental health impact of the COVID-19 outbreak in pregnant women and mothers of young children.

Methods

Research Design

The research study design implemented was a narrative inquiry. Narrative inquiry is relatively new among qualitative research designs when compared to other approaches like phenomenology, ethnography, and grounded theory. According to Connelly and Clandinin (1990), “the study of narrative is the study of the ways humans experience the world”. In this perspective, participants provide the researcher with their life experiences and thus interpret their own experiences by telling their individual stories in their own way in an interview. (Connelly & Clandinin, 1990; Scheffelaar et al., 2021). According to Scheffelaar and collaborators (2021), the research findings are a joint product between the participants who share their perspective of a topic and the interpretation of the research team through the process of analyzing the transcriptions.

Participants

We recruited the participants from the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort study composed of pregnant women and mothers of children 12 months or younger from the North Region of Puerto Rico. The PROTECT Center is a Superfund Research Program established in 2010 to study the role of environmental contaminants on preterm births in Puerto Rico. We invited the women from the PROTECT cohort through referrals from the research staff. The inclusion criteria were that they were over 18 years old, were pregnant, and gave birth during the COVID-19 pandemic. The 10 participants who were interviewed were between 21 and 40 years old, 4 of them were housewives, and 5 of them were employed and 9 of them were married or living with their partners. Also, 7 of them had gone to university (4 had a B.A. and 3 had a doctoral degree) and 6 of them reported an annual income between $10,000 and $24,999. All of the participants gave birth between March and September of 2020. The IRB at the University of Puerto Rico, Medical Sciences Campus (Protocol No. B3300120) approved this study.

Data Collection

The participants were contacted by phone explained the proposed study in detail and obtained informed consent. Once verbal consent was obtained, the research staff coordinated a date for the interview using the Zoom video conference platform. The interview duration was approximately one hour. Data collection was conducted from June to July 2021. The interview guide included the following sections: pregnancy and birth experiences, the impact of the pandemic on physical and mental health, the impact of the pandemic on family dynamics, healthcare services, and access, and social and emotional support. It was developed based on the specific aims. The research staff uploaded the recording with the participants' ID and completion date to a Dropbox file and sent a copy of the consent form to the clinics affiliated with PROTECT.

The interviews were conducted by three members of the research team, two women and one man. All have backgrounds in social sciences, one has a PhD in Organizational Psychology, one has a master’s in Public Health Education and pursuing a doctoral degree in Social Determinants of Health, and one is in the process of completing a master’s in Demography. One worked as a Communications Liaison of the RCMI Community Engagement Core and the other two were graduate students and research assistants in the PROTECT Center. All interviewers had experience conducting qualitative interviews previously and also participated in research team meetings to discuss the logistics and review basic interview techniques. The PI for Community Engagement in the PROTECT Study joined the interviewers for the analysis of the transcripts. The PI is an experienced qualitative investigator. The members of the research team did not have a previous relationship before the study and the participants only knew that they were members of the PROTECT team and conducting interviews about their experiences during the COVID-19 pandemic. All interviewers had an interest in research related to maternal health, and social determinants of health and were aware of the challenges related to the pandemic among pregnant and postpartum women due to the preliminary results from the survey.

Data Analysis

Interview recordings were transcribed and uploaded to NVivo software for qualitative analysis. Specifically, the thematic analysis was used. This is a method of systematically identifying, organizing, and providing insight into patterns of meaning (themes) across a data set (Braun & Clarke, 2012). This analysis is useful since, as Braun and Clarke (2012) established, it allows to question those latent meanings, that is, the assumptions and ideas behind what is stated explicitly. The research team developed a codebook based on the interview questions and used the thematic categories to codify the narratives. The themes were derived from the interview questions which in turn were derived from the specific aims of the study. The codebook was developed before the interviews were transcribed and was reviewed by the research team to include their recommendations.

The final version of the codebook had nine major categories: (1) pregnancy and birth process, (2) impact of the pandemic on health, (3) access to health services, (4) family dynamics during the pandemic, (5) difficulties faced during the pandemic, (6) strategies to manage challenges during the pandemic, (7) emotional support, (8) social support, and (9) other themes (see Table 1). The other theme category served to codify verbalizations where participants talked about topics that were not related to the interview questions, for example, participants mentioned vaccines, the role of faith, and the impact of mass media. Three research team members coded each of the ten interviews independently. Finally, the research team, composed of five people, proceeded to have group meetings to revise and reach a consensus regarding the analysis.

Table 1.

List of thematic categories used in qualitative analysis (Abridged Codebook)

Thematic Category
1. Pregnancy and birthing process
1a. Expectations
2a. Differences with other pregnancies
3a. Support during the process
2. Impact of pandemic on health
2a. Impact on mental health
2b. Impact on mood
2c. Impact on sleeping habits
2d. Impact on appetite
2e. Loneliness
3. Access to healthcare services
3a. Experiences in receiving services
3b. Treatment from providers
3c. Orientation about the birthing process
3d. Treatment from providers after birth
4. Family dynamics during pandemic
4a. Lockdown challenges
5. Challenges faced during pandemic
5a. Work
5b. Finances
5c. Childcare
5d. Family relations
5e. Wellbeing
6. Strategies to manage challenges associated with the pandemic
7. Emotional support
7a. Type of support
7b. Usefulness of support
8. Social support
8a. Type of support
8b. Usefulness of support
9. Other themes

Results

The interviews provided rich and diverse stories from women who experienced pregnancy, birth, and postpartum during the COVID-19 pandemic in Puerto Rico. The participants’ narratives were translated from Spanish and edited minimally to facilitate comprehension. Here are the most relevant themes that were found in their stories, which can help illustrate the challenges and coping mechanisms related to maternal health during pandemic times among 10 Puerto Rican women. Findings are organized in the following overarching areas: (1) pregnancy and birthing process, (2) orientation about the birthing process, (3) access to healthcare services, (4) impact of the pandemic on health, and (5) challenges related to taking care of children.

Pregnancy and Birthing Process

This category refers to participants’ expressions about the pregnancy and childbirth process during COVID-19; these also include the expectations they had during the pregnancy and delivery process and whether or not they were met. Some participants expressed that the birthing process, in particular, was challenging in part due to the protocols in place, which led them to feel isolated and without adequate support. For example, participant #3 said:

“Well, as I told you right now, frustrated, it was frustrating because my husband had always been with me, and maybe if he had been there, the trauma would have been a little less, right, because he would have been there giving me support and that was frustrating for me on that side, it was frustrating that they told me that he was not going to be there, it was frustrating.”

Another participant (#4) described the pregnancy experience as fine, but the process was so traumatic that she did not want to go through it again, and she decided to subject herself to a sterilization process after her first and only pregnancy (see Table 2). This same participant (#4) expressed that the treatment from healthcare providers in the hospital made her feel that they did not have empathy and did not allow her to bond with her newborn:

“Well, I felt like I had been violated, as if they had taken your rights and they had thrown them overboard...as if you didn't have the right... It was like the opposite of what they had given you in these childbirth classes and so on. They explained to you that you had rights as a mother, it was as if none of that was real, as if I had spent my money and my time to learn something that in reality, at the moment of truth, they did not apply it...And they didn't even have empathy because you know. I wanted to breastfeed my son, that was a goal for which I had been preparing several months before but they don't even tell you that they are going to take him away, they don't tell you that you have to be alone...”

Table 2.

Additional participants’ narratives about the impact of COVID-19 on maternal health in Puerto Rico

Thematic Category	Participants’ verbalizations
Pregnancy and birthing process	Participant #4 “Well, during the pregnancy process, I didn't stop going to my appointments and so on. But I did stop going out to places normally. I did not meet with anyone, like I stayed at home with my partner and the baby. But the labor process did affect me because my partner could not enter. When I gave birth, he only came in when the baby was practically outside, so I was alone throughout my entire process. And that marked me, it marked me to the point that I had surgery. That is what I am recovering from. I sterilized myself because I said that I never wanted to go through that process…again, giving birth alone, with fear and well, without anyone. So my pregnancy process did not affect me, but the labor process did.”
Orientation about the birthing process	Participant #4 “ …in reality they didn't explain a lot to us, they told us was which floor to go to and with the order, like with pre-admission and everything, like to which hospital we had to go, which floor we had to go to and so on. But about how many people were allowed, how long they were going to leave the baby with you, we were not clear about that. We did believe that it was only one person, but not even that because as I explained, my partner could not enter. So my son… I couldn't even touch him properly as soon as…he was born I did see him but they took him away. You know I couldn't breastfeed him, I couldn't like have that moment of postpartum intimacy with him. I couldn't because as soon as he came out, they showed him to me and took him away. You know, they didn't even give me a chance to be with the baby, nor did I put him on my chest or anything.”
Access to healthcare services	Participant #8 “But the government [public health insurance] kind of takes time in making the appointments. And the government [public health insurance], almost all the majority of the people have it and it is more difficult. And then, since I had the private one and I need to do those glucose studies. But since they already took away my plan (insurance), I have to look for another alternative that I can use in an emergency….Exactly, when it (insurance) was private everything was faster.”
Impact of pandemic on health	Participant #4 “Well, look, I don’t know if it is the fact that it changed all your routine and your lifestyle and the uncertainty that you don’t know if you're going to die or if your son, he's going to get Covid or what is going to happen to you that, I actually spent my time crying and crying all the time and in depression. Like I couldn't even get out of bed. No no, I couldn't even go and take a bath… things that are normally what one does on a day-to-day basis, well I couldn't do them because in reality, no, I didn't even feel like doing them out of fear, because I kind of thought like, like everything was lost. This was my first pregnancy and then I am going through something that I could lose it, because no one knew what was happening to you, if you… if you got Covid and you were pregnant because then at that time it was also that the news came out of this girl in the Manatí hospital who was pregnant and died… and I think even the baby died too. So those things started to hit me very hard and well my mental health was in decline…”
	Participant #5 “Sometimes yes. Yes, I mean, I say it because, because although I have great support from my husband, he goes out to work. Many times he is late because then he also takes care of my tasks like, go shopping, now he does everything….So although he is also tired, like everyone, you know, everyone, in every situation we are exhausted by the pandemic, but anyway I know that he gets distracted, at work, uh… he always finds himself from time to time for x or y reason with some friends. As opposed to me, I'm very locked up, when I say lock up I'm very locked up in my house.”
	Participant #7 “Yes, exactly, not having help and not being able to get together when, also when Christmas came… we were still, we couldn't celebrate it together, at that time.”
Challenges related to taking care of children	Participant #7 “We used the television a lot and that has been negative because, well…that’s what he wants from the moment he gets up is to watch the television until he goes to bed… yes, the skills that he must develop, how to paint, how to grip a pencil and that he should already be doing has taken him more time.// The boy had problems, well, it wouldn't be difficulties, in that case it was positive, because he also had, at that moment he was receiving speech therapy, and having the lockdown, in part the television helped him with that…he began to talk a lot as he was watching [TV] so he began to talk a lot, something that he did not do before.”

Access to Healthcare Services

We were able to document participants’ expressions related to accessing health services during the pandemic. This included positive or negative descriptions of receiving health services as well as the behavior of health service providers. Some of the participants mentioned that the pandemic affected their access to healthcare services due to changes in operation hours, which sometimes led to delays in obtaining appointments. For example, participant #1 said:

“It has affected me a lot because I have spent months trying to find, an appointment with my primary doctor, and... when I managed to make an appointment, they told me three, or four months from now... Then, the day came and I was absent. You know that, that it has - it has affected me a lot in that area, because it seems that they were taking a certain - a certain amount of people and they don't open every day, so that impacts a lot.”

However, other participants (#4) mentioned that they felt the pandemic had little to no impact on receiving maternal healthcare:

“...it didn't affect me that way in part, I'm telling you because since I never stopped going to my prenatal appointments and I never had any difficulty getting the medicines or the prenatal pills or the iron that they prescribed, I did not have much difficulty.”

Participants also highlighted the difference between having private vs public health insurance as an important matter to their healthcare access. A participant (#8) who had previously had private insurance but switched to public insurance mentions the differences in getting appointments (see Table 2).

Orientation About the Birthing Process

This sub-category refers to participants’ expressions about the process of receiving orientation or lack of orientation concerning the protocols related to the childbirth process from their health providers. Some participants said that their doctors explained the protocols in place at hospitals to them, and prepared them for what to expect. For example, participant #3 said:

“Well, I went there, I talked to the doctor and I explained to him, my concerns, look, doctor, what would the birth process be like now with this pandemic, so he told me from this moment on, you know about that appointment, the pandemic just started, he told me, look, well, yes you are a natural birth, you will be able to enter as soon as you go into labor when you go there almost to give birth, then the husband will be able to enter the room, he tells me if it is a cesarean section, he will not be able to enter because it is the hospital rules, it was what he told me, you know that it wasn't a rule that he set, but that it was the rules of the hospital.”

However, other participants mentioned that they didn’t receive an orientation, and certain expectations were unmet. Participant #4 received orientation regarding the pre-admission process but not in terms of the limitations of companions during the birth and was not able to properly bond with her newborn (see Table 2).

Impact of Pandemic on Health

This category refers to the expressions about the impact of the COVID-19 pandemic on their health in general. However, the main focus of the narratives in this category is related to mental health (stress, depression, anxiety) and loneliness (feeling alone or isolated).

Mental Health

The isolation and uncertainty associated with the pandemic, particularly in the early stages of the lockdown and lack of treatment or vaccines, negatively impacted the mental health of some of the participants interviewed. For example, participant #4 shared the following. She also explained both the cause and the severity of her depressive symptoms (see Table 2).

“How do I compare? Wow... Well... I think that right now it is much better than in the pandemic because well, in the pandemic one is being locked up, unable to get out and all this from a disease that nobody knows about, it kind of puts you physically and mentally in a very delicate state, and once I identified the state I was in, I began to seek help because I fell into depression. So' now with the help of therapy I find that my mental and physical state is much better now than when the pandemic began.”

Meanwhile, other participants mentioned strategies they used to manage their mental health. Participant #1 mentioned:

“Honestly, I controlled my mental health, I controlled it myself because if I didn't, - I say again-, I, I know myself and I can become obsessed, uh, and, I get paranoid. But, at least I, at least I controlled my mind and, and, and today I feel at peace, I'm not afraid of it, you know, uh, I obviously take care of myself but now I see everything so different too.”

While participant #5 expressed:

“So, both during the pregnancy and now, I work at the moment and look for a way, I look for a way to feel my emotions, to recognize them and then work on them. Like, if I feel very worried or sad, then I look for another activity to do, I try to work on the part of gratitude, of what I have, even when it is not under the most favorable circumstances...”

Loneliness

Not all participants expressed experiencing loneliness, instead, they said they felt supported even while practicing social distancing measures. For example, participant #3 shared:

“But at least in my case, thank God, no. You know, I have not felt alone, I have always felt accompanied by my family, my daughters, my in-laws, my parents, you know I have always felt, right, that warmth and support from them.”

However, others mentioned that the lack of physical contact with family members was challenging and led them to feel a lack of social support which made them feel lonely. Participant #7 said the following statements:

“him [the baby] not being able to have this interaction with more family and that and when I needed to take the baby to the doctor and I have another big one... not having that kind of support, yes, I felt alone.”

The participants’ experiences also illustrated the relationship between loneliness and mental health; for example, participant #7 mentioned that:

“When work was happening, my family wasn't there, but at least I had the support of my mother, my husband... in that sense, well, I didn't feel alone, I was depressed but I didn't feel alone.”

In this case, even when feeling supported, she struggled with her mental health. Meanwhile, others felt misunderstood because of their isolating experience of being stuck at home for an extended period of time (see Table 2). This also relates to the difference in gender roles when it comes to the private domestic sphere and the public sphere. Later in the interview, she says:

“So, I did feel alone because I felt that no one really understood what I was going through and at the same time, I didn't want to be like complaining all day.”

Challenges Faced During the Pandemic

This category refers to narratives related to the difficulties faced during the pandemic in different areas of their lives, like work, finances, childcare, family relationships and well-being.

Challenges Related to Taking Care of Children

This sub-category refers to expressions related to the difficulties raising their children during the pandemic, particularly regarding education. Participant #3 told us:

“...that I had to experience being a teacher too...and as I can tell you this my mood well, oh my God, how can I tell you, well, happy, frustrating. Well... one [of my daughters] was in the sixth grade and one was in the first grade.”

Participant #10 described the multiple roles she had to embrace during this time, which also sheds light on the impact of gender roles regarding caretaking duties: “… I had to play the role of mother, wife, housewife and teacher…”.

In regards to this particular topic, participant #2 relates her experience and the different roles she and her husband took in regards to parenting:

“my husband obviously works and when he arrived he left his clothes somewhere in the canopy (outside), he went in, he went to bathe, he didn’t come close, he almost never went near the girls, he was always wearing a mask...he carries her now that she’s one year old because he didn't carry her or anything, for fear that he was exposed at work...”.

Other participants mentioned negative but also positive aspects to parenting during the pandemic like how isolation hindered socialization opportunities but also offered a buffer from external judgment regarding parenting choices. For example, participant #7 mentioned the detrimental and beneficial role that television played in her son’s development (see Table 2).

Discussion

Our results highlight the experiences of 10 women who were pregnant and/or gave birth during COVID-19 in the northern karst region in Puerto Rico and show how the pandemic impacted their pregnancy, birthing experiences, and their mental health. Their narratives illustrated the specific challenges this population faced in relation to this emergency and gave us an idea of the importance of social support as a protective factor for mental health.

In regards to specific aim 1, which was to examine the impact of the COVID-19 outbreak on pregnancy-related experiences and outcomes, participants’ narratives showed how the pandemic and the restrictions to curb its spread changed plans and expectations regarding the pregnancy and the birthing process. For example, several participants mentioned that they did not receive proper orientation about the birthing process. They had to essentially give birth unaccompanied and were unable to bond with their baby right after birth. These restrictions, according to recent studies, have affected the quality of maternal and newborn care and in consequence, impacted their mental health negatively (Kotlar et al., 2021; Chrzan-Dętkos et al., 2021; Lazzerini et al., 2022). In Puerto Rico, recommendations for hospitals (i.e., separation of baby and mother after birth and restrictions of people in the delivery room) were placed to prevent contagion in case of a positive or suspected case of COVID-19. However, Rivera Orraca and collaborators (2021) mentioned that they were used as a general practice for both positive and suspected and negative cases by the healthcare system. The women’s narratives confirm this, as none of them mentioned being COVID-19 positive at the time of birth, yet they were forced to follow these restrictions.

In regards to specific aim 2, which was to examine the mental health impact of the COVID-19 outbreak in pregnant women and mothers of young children, participants’ narratives showed that physical distancing led to social isolation and, in some cases, depression and feelings of loneliness. Culturally, the baby shower represents not only an opportunity to receive necessary supplies but also an occasion to celebrate the arrival of the newborn. However, due to the pandemic, many women had to cancel their baby showers or decided to have them virtually. Some participants expressed they were not affected much by restriction measures and felt supported even though they had little to no physical contact with their extended family. In addition, we identified other themes discussed in the interviews that were not contemplated for our specific aims, like changes in access to healthcare services due to the pandemic and challenges related to taking care of their children.

The pandemic put stress on the healthcare system, which has led to the diversion of resources, reorganization of services, and financial and physical barriers, resulting in difficulty accessing sexual, reproductive, and maternal health services (WHO, UNFPA, UNICEF; 2020). Some participants experienced challenges in booking appointments and regarding availability of services; meanwhile, others expressed that they did not experience a significant difference in access to medical services for themselves and their children. According to the CDC (2019), public health emergencies like pandemics can present unique challenges to pregnant women and mothers of young children. Other challenges mentioned by, some participants were how they had to essentially become teachers due to long-distance learning and balance this role with motherhood and sometimes work. This is consistent with the literature that establishes that the differential impact of the pandemic on this population can be traced to the significant presence of women as frontline healthcare workers and in other essential jobs, their role as family caregivers, and the greater likelihood of living in conditions of poverty (Rasmussen et al., 2008; Wenham et al., 2020).

In general, the literature cited previously showed that the impact of the pandemic on maternal health was similar independent of context. There were studies from Europe (Lazzerini et al., 2022), the United States (Liu et al., 2021), and Puerto Rico (Rodríguez Reynaldo et al., 2023) and the results indicated that the restrictions due to social distancing measures affected the perceived quality of the birthing process and interrupted social support networks in post-natal period as well. However, Puerto Rico is a unique case due to the compounded effect of consecutive emergencies, especially the hurricanes and economic crisis and this should be studied in further detail in future research endeavors.

The findings from the interviews conducted reflected the challenges experienced by pregnant women regarding the COVID-19 pandemic. Specifically, the negative effect that social distancing measures had on their birthing process and the postpartum period. From the participants’ perspectives, we can infer that the challenges faced were directly related to the pandemic and not a compounded effect of the several emergencies experienced in Puerto Rico in the last seven years. However, the questions from the interview were directed towards how the pandemic impacted their experiences and did not ask about the compounded effects of successive emergencies and social issues.

Regarding the limitations of this study, we should consider that the sample did not include participants from all areas of the archipelago but only focused on women from the northern karst region in Puerto Rico. Another possible limitation is the recall of events and experiences since the interviews were done after the pregnancy and birth had already passed. In terms of future directions, the research team would like to compare these results, along with the results from the quantitative phase of the study, with findings from the impact of hurricanes Irma and María in 2017 on maternal health. This can contribute to a better understanding of risk and protective factors related to maternal health in emergency situations. Secondly, use these findings that were presented in the results section to design interventions for caretakers (i.e. mothers, immediate family) and healthcare providers for emergency preparedness. Finally, we consider it important to encourage the promotion of public policies and services that consider the unique challenges of this population in emergency situations and ensure that there are resources available for their implementation.

Author Contributions

Data collection: NHO, AGV, GAC, IA, NG, JM, MC, SC. Conceptualization: ILP, NHO, AGV, GAC, CVV. Visualization: ILP, NHO, AGV, GAC, CVV. Writing-original draft: ILP, NHO, AGV, GAC, CVV. Writing-review and editing: ILP, NHO, AGV, GAC, CVV. Funding: JC, AA.

Funding

This project is supported by the Center for Collaborative Research in Health Disparities (CCRHD), which is funded by an RCMI-Grant from the National Institute on Minority Health and Health Disparities (U54 MD007600) at the University of Puerto Rico, Medical Sciences Campus and also a research project funded by the National Institute of Environmental Health Sciences, National Institutes of Health (P42ES017198, ECHO UG3OD02351).

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to containing information that could compromise the privacy of research participants.

Code Availability

Not applicable.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

The IRB at the University of Puerto Rico, Medical Sciences Campus (Protocol No. B3300120) approved this study.

Consent to Participate

The participants received orientation from the research staff and signed an informed consent form.

Consent for Publication

The informed consent form included a statement about the publication of data while protecting their identity.