Table 3.

Hypotheses for how the COVID-19 crisis may exacerbate known risk factors for postnatal depression.

Established risk factor for postnatal depression (numbers listed in brackets are per Table 2)	Hypotheses: Exacerbated by COVID-19 crisis? [strongly decreased, weakly decreased, N/A, weakly increased, strongly increased]	Examples of contextual factors that may be interacting with this risk factor	Disaster-related rationale for hypotheses
[1] Presence of depressive symptoms during pregnancy	Strongly increased	Home isolation; social and physical distancing; some antenatal and postnatal supports have ceased operating; reduced physical activity; cumulative losses; increased media exposure.	Increased rates of depression symptoms experienced in populations following disasters (5), and currently observed in relation to COVID-19 (28, 29). Reduced rates of physical activity reported for those in the perinatal period during COVID-19 pandemic (29).
[2] Presence of symptoms of common mental disorders (other than depression and anxiety) during pregnancy	Weakly increased	Home isolation; social and physical distancing; some antenatal and postnatal supports have ceased operating; reduced physical activity; cumulative losses; increased media exposure.	Increased rates of psychopathology currently observed in relation to COVID-19 (28).
[3] Prior diagnosis of a depressive disorder	N/A for the cohort pregnant and/or giving birth during the COVID-19 pandemic
[4] Prior diagnosis of an anxiety disorder including prenatal anxiety	Strongly increased	Home isolation; social and physical distancing; some antenatal and postnatal supports have ceased operating; reduced physical activity; cumulative losses; increased media exposure.	Increased rates of anxiety symptoms experienced in populations following disasters (5), and currently observed in relation to COVID-19 (28, 29).
[5] Family history of psychiatric illness, during or prior to pregnancy, including genetic risk factors	N/A for the cohort pregnant and/or giving birth during the COVID-19 pandemic
[6] Perceived low social support during pregnancy	Strongly increased	Home isolation; social and physical distancing; reduced visitations from social supports; some postnatal supports have ceased operating; reduced time in hospital; reduced number/length of medical appointments.	Social support can alleviate the stress caused by disaster, however it appears to depend on whether support structures are created or destroyed (5). It appears that COVID-19 is likely to reduce the likelihood that social supports can be effectively accessed, thus perceived social support is likely to be lower.
[7] Perceived low support from partner	Weakly increased	Partners may be physically present in the home whilst working from home; possibly increased interpersonal partner conflict from containment in the home for long periods.	Social support can alleviate the stress caused by disaster, however it appears to depend on whether support structures are created or destroyed (5). It appears that COVID-19 may have mixed impacts regarding partner relationships with some partners more able to support when working from home, whereas other families may experience increased interpersonal partner conflict from containment in the home for long periods (17).
[8] History of childhood sexual abuse	N/A for the cohort pregnant and/or giving birth during the COVID-19 pandemic
[9] Exposure to traumatic events during or prior to pregnancy specifically including physical domestic and family violence	Strongly increased	Home isolation; social and physical distancing; reduced visitations from social supports; changes in hospital policies, for instance, separation of COVID-19 positive mothers from their newborn infants for 14 days in China (9); no birth partners in the labor ward (e.g., in New York in the United States of America).	Domestic and family violence expected to increase during disaster, particularly the COVID-19 crisis (17). Additionally, for some women the impact of changed hospital policies in times of disaster may be perceived to be traumatic.
[10] General stress (i.e., Generalized high allostatic load including the stress hormone cortisol and plasma-derived inflammatory biomarkers)	Strongly increased	Home isolation; social and physical distancing; reduced visitations from social supports; some postnatal supports have ceased operating; reduced time in hospital; reduced number/length of medical appointments; media exposure; financial stress associated with employment uncertainty (e.g., loss of employment hours).	Emerging research from the COVID-19 crisis indicates high levels of stress and associated psychopathology in the general population (6), and high levels of stress have also been recorded within perinatal populations (28).
[11] Significant life events occurring during pregnancy or immediately post-partum (e.g., death of a loved one; loss of employment; relationship breakdown or divorce; relocation including moving house)	Strongly increased	COVID-19 may in itself be perceived as a significant life event; women may experience death of a loved one due to illness from COVID-19; women may not be able to mourn the death of a loved one in culturally expected ways due to imposed restrictions; loss of employment may be experienced for self or other family members; relationship strain from containment in the home for long periods may result in relationship breakdown or divorce.	No direct evidence identified from previous disasters.
[12] Marital dissatisfaction leading to complications (including psycho-emotional but not physical domestic and family violence)	Weakly increased	Partners may be physically present in the home due to working from home; possibly increased interpersonal partner conflict from containment in the home for long periods; unequal caring and/or home-schooling duties may increase dissatisfaction.	Positive social support from partners can reduce the stress caused by disaster, however not all partners provide positive social support (5). Interpersonal partner conflict and marital dissatisfaction may be amplified within some families (17).
[13] Adverse obstetric factors (e.g., pre-eclampsia; hyperemesis; premature labor including Cesarean section; intrapartum bleeding; pre-term birth)	N/A
[14] Severe neonatal complications including congenital malformations	N/A
[15] Low socioeconomic status (i.e., low average income and/or high cost-of-living)	Weakly increased	Loss of employment for self or other family members may change the experience of socio-economic well-being.	Economic factors, such as family income and employment, have been linked to poor maternal mental health after earthquakes (5).
[16] Specific culture-bound factors (e.g., spousal disappointment with sex of fetus/infant; imposition of strict gender roles during and after pregnancy)	N/A
[17] High stress associated foremost with care of index child but including other young children	Strongly increased	Home isolation with reduced visitations from social supports may increase the perceived stress associated with the index child, and high stress may result from reduced care options (i.e., keeping other children home from care; home schooling; etc.).	No direct evidence identified from previous disasters.
[18] Failure to adhere to psychiatric medications including those prescribed to manage depressive symptoms	N/A
[19] High maternal neuroticism	N/A
[20] Low maternal self-esteem and/or self-acceptance	N/A
[21] Difficult infant temperament	N/A
[22] Ambivalence associated with parenting, including unplanned pregnancy	N/A
[23] Historical diagnosis of other common mental disorders	N/A for the cohort pregnant and/or giving birth during the COVID-19 pandemic
[24] Adverse experiences associated with immigration (e.g., racial/ethnic discrimination, delayed visa status/uncertainty surrounding immigration status, poor access to health services, low language ability for country of settlement)	Weakly increased	Physical distancing; change in economic climate.	Possible increased uncertainty surrounding immigration status with possible longer wait times; access to health services may be impacted; and ability to source help services without face-to-face interaction may be increasingly challenging.
[25] Giving birth at age extremes (i.e., very young or older mothers)	N/A