OBJECTIVE: The rates of postpartum depression (PPD) or anxiety have increased during the COVID-19 pandemic1; for example, in Canada, the rates of prepandemic depression and anxiety ranged from 10% to 15%, but they are 37% during the pandemic.2 To date, however, data remain scant on the risk factors for developing the symptoms of PPD or anxiety during the pandemic, particularly among women who did not have preexisting mental health issues. However, these data could help providers give targeted support for women delivering during the pandemic, who are at an increased risk for postpartum depression or anxiety symptoms. This study aimed to investigate the factors associated with the development of PPD or anxiety symptoms during the COVID-19 pandemic among women who delivered during the year before and did not report having symptoms of depression or anxiety.
STUDY DESIGN: Women were recruited from the Hassenfeld Study from July 29, 2020 to October 23, 2020. This study is an ongoing institutional-review-board-approved large, diverse prospective cohort study in Rhode Island; it examines the effect of environmental factors on maternal and pediatric outcomes during pregnancy and early childhood. Participants who delivered within the previous 12 months and maintained primary custody of their child were eligible for this study, which was done through a survey administered via telephone. Women completed the validated psychometric screening tools—the patient health questionnaire-2 (PHQ-2) and the generalized anxiety disorder-2 item screening (GAD-2) to assess for self-reported symptoms of PPD and anxiety, respectively. The PHQ-2 has high sensitivity for PPD symptoms,3 whereas the GAD-2 has high specificity for perinatal anxiety symptoms4; by focusing on the self-reported symptoms, neither scale can diagnose major depressive disorder or anxiety disorder per the diagnostic and statistical manual version 5 criteria. Women who endorsed symptoms of depression or anxiety before the pandemic were excluded from analysis, as the aim of the study was to identify the risk factors for symptoms of postpartum depression or anxiety among women who did not have these symptoms during or before pregnancy. To identify the risk factors for developing new PPD or anxiety symptoms, women self-reported on the COVID-19 symptoms and exposures, the perceived stress before and during the pandemic (using the perceived stress score-45), and employment, financial, or general concerns. The predictors were compared among those who did vs those who did not endorse new-onset PPD or anxiety symptoms during the pandemic.
RESULTS: A total of 329 women were eligible; of these, 241 (73%) participated. 204 did not endorse prepandemic symptoms of depression or anxiety. Of the 204 included women, 54 (26.7%) endorsed new-onset PPD or anxiety symptoms during the pandemic. There were no sociodemographic or obstetrical differences among the women who did vs those who did not endorse PPD or anxiety; overall, 36% were Hispanic (Table 1 ). Although the rates of reported stress before the COVID-19 pandemic were similar among the 2 groups, the women who developed PPD or anxiety symptoms had higher perceived stress at survey completion (perceived stress score 4 mean (standard deviation) 7.7 (2.1) vs 4.6 (2.6); P<.0001). Those with PPD or anxiety symptoms were more likely to endorse being concerned about the availability of food or household supplies or the lack of social distancing. Women who had PPD or anxiety symptoms were more likely to report that their own job or the job of someone they depended on financially had been designated as essential (64.9% vs 45.8%; P=.03), to believe that this job increased the risk of COVID-19 exposure (59.3% vs 42.8%; P=.04), or to report that a family member had been diagnosed with or presumed to have COVID-19 (27.8% vs 12.8%; P=.01) (Table 2 ).
Table 1.
Sociodemographic and obstetrical factors affecting postpartum mental health during the COVID-19 Pandemic
| With COVID-19onset anxietyand/ordepressionn=54 (26.7%) | Without COVID-19onset anxietyand/ordepressionn=148 (73.3%) | P value | |
|---|---|---|---|
| Maternal age | |||
| Mean (SD) | 30.5 (5.1) | 30.6 (5.9) | .97 |
| Maternal ethnicity | .25 | ||
| Hispanic | 23 (42.6) | 50 (33.8) | |
| Non-Hispanic | 31 (57.4) | 98 (66.2) | |
| BMI at first prenatal visit | |||
| Mean (SD) | 29.7 (5.7) | 28.8 (6.7) | .41 |
| Obstetrical/perinatal factors | |||
| Multiparous | |||
| Yes | 33 (61.1) | 88 (59.5) | .83 |
| Mode of delivery | .26 | ||
| Vaginal delivery | 42 (80.8) | 108 (73.0) | |
| Cesarean delivery | 10 (19.2) | 40 (27.0) | |
| GA at delivery (wk) | |||
| Mean (SD) | 39.3 (1.6) | 38.8 (2.0) | .10 |
| Number of children <18 living at home during the time of interview | |||
| Median (min-max) | 2 (1-4) | 2 (1-6) | .75 |
| Age of infant at the time of interview (mo) | |||
| Mean (SD) | 8.8 (2.5) | 9.0 (2.1) | .68 |
BMI, body mass index; GA, gestational age; SD, standard deviation.
Lewkowitz. Risk factors for postpartum depression or anxiety during COVID-19. Am J Obstet Gynecol MFM 2021.
Table 2.
COVID-19-pandemic-related experiences, changes, and concerns among postpartum women
| With COVID-19onset anxietyand/ordepressionn=54 (26.7%) | Without COVID-19onset anxietyand/ordepressionn=148 (73.3%) | P value | |
|---|---|---|---|
| Women or someone living in the household had or probably had COVID-19 | .01 | ||
| Yes | 15 (27.8) | 19 (12.8) | |
| Perceived stress score before the COVID-19 pandemic (PSS-4) | |||
| Mean (SD) | 3.6 (2.2) | 3.0 (2.6) | .13 |
| Perceived stress score during the COVID-19 pandemic (PSS-4) | |||
| Mean (SD) | 7.7 (2.1) | 4.6 (2.6) | <.01 |
| Difference in PSS-4 (COVID-19 Pandemic– Pre-COVID-19 pandemic) (positive means more stressed during pandemic) | |||
| Mean (SD) | 4.0 (2.4) | 1.6 (2.9) | <.01 |
| Money situation during COVID-19 pandemic | .07 | ||
| Comfortable with extras | 16 (29.6) | 70 (47.3) | |
| Enough but no extras | 17 (31.5) | 35 (23.7) | |
| Had to cut back or could not make ends meet | 21 (38.9) | 43 (29.0) | |
| Changes in work life because of COVID-19 pandemic for the mothers, their partners, or anyone else on whose income they dependa | |||
| Had permanent loss of job | 15 (33.3) | 30 (20.6) | .34 |
| Had a temporary loss of job (eg, furlough) | 16 (29.6) | 44 (30.1) | .95 |
| Had their hours reduced | 24 (44.4) | 40 (27.6) | .02 |
| Had their pay decreased | 13 (24.1) | 34 (23.3) | .91 |
| Had decreased job security | 17 (31.5) | 28 (19.3) | .09 |
| Had increased responsibilities | 28 (51.9) | 62 (42.5) | .24 |
| Had their job designated as an essential service | 35 (64.9) | 66 (45.8) | .03 |
| A job that causes an increased risk of COVID-19 | 32 (59.3) | 62 (42.8) | .04 |
| Moved to remote work/work from home | 22 (40.7) | 53 (36.3) | .56 |
| Concerned about in relation to the COVID-19 pandemica | |||
| Not being able to pay for basic needs such as rent/mortgage, food,medicine, baby supplies | 29 (53.7) | 65 (43.9) | .22 |
| Being evicted | 12 (22.2) | 22 (14.9) | .29 |
| Availability of food | 26 (48.2) | 41 (27.7) | <.01 |
| Availability of baby supplies (such as formula, diapers, wipes) | 23 (42.6) | 55 (37.2) | .48 |
| Availability of personal care products or household supplies | 32 (59.3) | 55 (37.4) | <.01 |
| Losing your job | 27 (50.9) | 43 (34.1) | .04 |
| Your partner or someone you depend on for income losing their job | 21 (41.2) | 41 (29.3) | .12 |
| Loss of health insurance | 18 (33.3) | 33 (22.3) | .14 |
| Not being able to access medical care for yourself or your familybecause of the virus | 26 (48.2) | 62 (41.9) | .43 |
| Not being able to access mental healthcare for yourself or your family | 22 (40.7) | 49 (33.1) | .32 |
| That some people are not social distancing | 41 (80.4) | 86 (58.5) | <.01 |
| Being quarantined | 29 (53.7) | 67 (45.3) | .29 |
Data is presented as number (percentage) unless indicated otherwise.
PSS-4, perceived stress score 4; SD, standard deviation.
Only reported “yes” answers.
Lewkowitz. Risk factors for postpartum depression or anxiety during COVID-19. Am J Obstet Gynecol MFM 2021.
CONCLUSION: In this diverse cohort of postpartum women who did not report having symptoms of depression or anxiety before the COVID-19 pandemic, more than one- fourth developed PPD or anxiety symptoms during the pandemic. The high rate of new-onset PPD or anxiety symptoms may be because of stressors associated with the COVID-19 pandemic. This is potentially compounded by social distancing practices, isolating mothers with young infants from getting in-person support from those who do not live in their households. By identifying the risk factors such as being concerned about food availability or having a household member employed as an essential worker, these findings can help guide future public health initiatives aiming to mitigate the risk of PPD or anxiety symptoms and provide targeted support for women who deliver during the current or future pandemics.
Footnotes
The authors report no conflict of interest.
References
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