Exploring the psychosocial impact of the Covid-19 pandemic on women’s perinatal experiences and wellbeing: A qualitative study

Abstract

Objective

While many studies have investigated the clinical impact of the Covid-19 pandemic on pregnant women’s mental health, little attention has been paid to the exploration of women’s experiences during the perinatal period from a psychosocial perspective in the Italian context. Thus, the present study aimed to explore the psychosocial changes associated with the pandemic in the perinatal context.

Methods

Twenty-one Italian women who gave birth between March and November 2020 took part in this research by participating in semi-structured interviews, exploring their childbirth experiences. Our data were analysed using a Grounded Theory approach.

Results

Our findings revealed the enhanced importance of social support as a protective factor against uncertainties, which strongly characterised all phases of the perinatal period during the pandemic. Such uncertainties were mainly linked to the discontinuity in intrapartum care, as well as to concerns of being infected with Covid-19 combined with other pregnancy-specific worries. The main sources of social support were represented by loved ones – most of all partners – along with health care staff and peer networks.

Conclusions

Our results suggest the importance of implementing evidence-based policies and interventions to improve women’s wellbeing in the perinatal period during the pandemic, as well as of guaranteeing intrapartum care continuity and the presence of social support.

Introduction

After the first recognised case of Covid-19 in December 2019 in Wuhan, the coronavirus outbreak quickly impacted the whole world, leading the World Health Organization to declare it a pandemic [1]. During the first months of 2020, Italy became the first European country to be affected by this disease, with 210,717 confirmed cases on 3 May 2020 [2]. Besides the well-documented impact on the lifestyle, habits, and physical and mental health of the general population [3], the pandemic has also profoundly changed maternity care procedures in most European countries [4], including Italy [2], with multiple negative consequences for women’s wellbeing [5]. First, the lack of scientific information about Covid-19 and the challenging situation that hospitals were facing during the first wave of the pandemic led to some restrictions, such as the limitation of face-to-face medical appointments [4], [6]. Moreover, in several EU countries, many hospitals adopted the exclusion of the patient’s “companion of choice” from delivery rooms as a measure to contain the risk of contagion [4], [6], [7]. Other issues that pregnant women faced due to the emergency included the cancellation of medical appointments [8], the impossibility of attending antenatal classes [6], the duty to wear a face mask during the delivery and the mother–child immediate separation [7].

In Italy, where the main caregivers for pregnant women are gynaecologists and obstetricians [9] (whose tasks correspond to the ones of a midwife [10]), the first phase of the pandemic was characterised by serious concerns about safer practices for pregnant women and new-borns [11]. Specifically, although the Italian Ministry of Health issued guidelines for pregnancy and delivery [2], intrapartum care still struggled to ensure continuity all over the nation; for example, some hospitals reduced antenatal appointments and suspended certain services (e.g., the epidural) due to the lack of anaesthesiologists, who had been reassigned to Covid-19 intensive care units [4]. Moreover, in some cases, decisions have been taken (e.g., routine separations of the mother and child immediately post-birth, access restrictions to patients’ companions, etc.) that may have jeopardised maternity care [11].

From a psychosocial point of view [12], women who experienced the perinatal period during Covid-19 could be considered an at-risk population due to the lack of social support [13] that, along with the difficulty of accessing care, may have exacerbated pregnancy-specific stress [14]. On the other hand, social support was already considered a protective factor for the wellbeing of pregnant women, both before and during Covid-19 [15], [16], as it helps to cope with psychosocial stressors with a “buffer” effect: this means that the impact of social support becomes more powerful when the stressor is stronger [15]. For these reasons, it is important to understand how women, especially in the Italian context, have experienced these changes and how Covid-19 has impacted their wellbeing during the perinatal period, by examining the phase that goes from the pregnancy to the postnatal period.

Out of several studies examining the impact of the Covid-19 pandemic on women’s physical and mental health during the perinatal period [17], [18], [19], to our knowledge, most of them adopted a clinical perspective, aimed at identifying the main symptomatologic manifestations resulting from the Covid-19 situation [20]. On the other hand, few qualitative works [13], [21], [22], [23] have explored in-depth how women in the perinatal period experienced the psychosocial changes imposed by the pandemic while also taking into account the already demanding path from pregnancy to postpartum. Therefore, the present study aimed to investigate how the first and second wave of the Covid-19 pandemic changed the perinatal experience in the Italian context, considering not only all the related phases (i.e., pregnancy, birth, and postpartum period) but also the experience of the intrapartum clinical pathway, and potential risk and protective factors, such as the presence or absence of social support, or the advent of new types of maternal stressors (e.g., Covid-19 related changes) from a psychosocial perspective.

Method

Design

This study followed the Grounded Theory Methodology, a systematic inductive method aimed at producing theoretical explanations of social processes based on qualitative data [24]. A Constructivist Grounded Theory approach [25] was chosen due to the centrality it ascribes to the interpersonal relationship between researcher and participants. This type of qualitative analysis seemed to be particularly suitable for the purpose of our investigation for at least two reasons: first, the issue (i.e., the impact of the pandemic on the perinatal period from a psychosocial point of view) had not yet been explored in-depth, so the lack of a solid theoretical background, and the consequent explorative approach, made this methodology particularly indicated; second, the characteristics of the population under investigation and the sensitivity of the topics addressed during the interviews needed an empathic context in which participants could feel supported and understood.

Sampling and recruitment

In line with the Grounded Theory Methodology, purposive sampling was used to recruit women who gave birth in the first stage of the Covid-19 pandemic, specifically between 11 February 2020, when the first cases of Covid-19 were recognised in Italy, and November 2020, during the second wave of the pandemic. Subsequently, theoretical sampling was used to supplement the data and reach saturation. Participants were recruited through Facebook groups dedicated to the themes of pregnancy and childbirth, inviting their members to participate in a study about pregnancy during the pandemic.

The total sample included 21 Italian women between 23 and 41 years old (M = 32.6; SD = 4.3) who gave birth between March and November 2020. No respondent tested positive for Covid-19 at the time of admission to the hospital, thus all mothers gave birth in a first-level hospital. Interviews were conducted between one and nine months after childbirth (M = 5.5; SD = 2.9). The participants’ characteristics are summarised in Table 1 .

Table 1.

Participants’ characteristics.

Characteristics	Frequency	%
Age
18–30	6	28.6
>30	15	71.4
Italian region of residence
Northern Italy	12	57.1
Central Italy	4	19.1
Southern Italy and Islands	5	23.8
Current marital status
In a romantic relationship	8	38.1
Married	13	61.9
Date of delivery
March-May 2020	9	42.9
June-August 2020	5	23.8
September-November 2020	7	33.3
Number of children
1	13	61.9
2	7	33.3
3	1	4.8
Delivery modality
Vaginal birth	12	57.1
Caesarean section	9	42.9
Presence of a companion during labour*
Yes	5	38.5
No	8	61.5
Presence of a companion during delivery
Yes	11	52.4
No	10	47.6
Satisfaction with childbirth
Not at all satisfied	1	4.8
Not very satisfied	0	0
Neutral	3	14.3
Somewhat satisfied	12	57.1
Very satisfied	5	23.8

*Note. This data was calculated only on women who went into labour (N = 13), since the remaining participants (N = 8) had a planned C-section.

Data collection

We conducted 21 semi-structured interviews between November 2020 and January 2021. The interviews were guided by a script designed to explore the characteristics of the respondents’ pregnancy and childbirth during the pandemic, the quality of their hospital experience, and their life after delivery, although the majority of questions were guided by the participants’ own words and willingness to discuss the topics proposed more in depth. Some examples of questions that were asked are “Can you please tell me about how you experienced your pregnancy, considering the context of the pandemic?”; “Can you please tell me about your labour and delivery?”; “What was your experience while in the hospital?”; “How did you experience your homecoming after the birth?”.

Before conducting the interviews, a brief personal data sheet was administered to the participants in order to record the sample characteristics and childbirth satisfaction (measured on a scale from 1 = “not at all satisfied” to 5 = “very satisfied”). According to the participants’ own preferences, the data were collected by telephone or video call to ensure the maximum level of comfort and confidence. Before each interview, the informed consent form was read to the participants, and they gave their consent both at the beginning and at the end of each interview. Verbal, rather than written consent, was chosen due to the pandemic context, which would have made it more difficult to obtain written consent. Furthermore, considering the qualitative nature of the research, verbal consent was a further modality to preserve anonymity. The length of the interviews was between 20 and 45 min.

Data analysis

After each interview, the collected data were transcribed verbatim; no sensitive information was recorded in order to maintain the participants’ confidentiality. The first phase, after the transcription, consisted of repeated readings of the interviews. The data were analysed using a three-step process. The first step began with open coding based on a descriptive level [26]. In this phase, 492 codes were identified, including some “in vivo codes” to capture the participants’ meaning and point of view. Then, the second step was focused coding, based on a conceptual level [26]. During this phase, 12 categories were recognised. The last step was theoretical coding, characterised by the maximum level of abstraction [26], in which 5 macro-categories were found and linked to each other and to the core category. Field notes and memos were written during data analysis to define emerging categories and relationships between codes and categories, following The Constant Comparative Method of Qualitative Analysis [27]. Although the authors differ in age and academic status, they share the same background in social psychology applied to health. The first author (FM) is a trainee psychologist, the second author (MC) is a psychologist and a PhD student, and the last author (DC) is a professor and has a PhD in Social and Health Psychology. Starting from the awareness of this shared perspective, the constant dialogue within the group made it possible to reflect on the possible impact of previous theoretical knowledge on the interpretation of the data, so that the coding remained anchored to the data as much as possible. The whole process was characterised by a constant discussion between authors of eventual disagreements or diverse interpretations of the data, to triangulate the results and ensure inter-rater reliability. Moreover, group discussions were a chance to further reflect on the eventual influence of pre-existing knowledge, attitudes, and beliefs on the analysis. The entire analysis process was conducted using Atlas.ti 8. SRQR criteria were used to reporting the results [28].

Ethical considerations

This study has received the ethical approval of the university committee. Theoretical sampling and theoretical saturation were used to ensure qualitative representation. Leading ethical standards included respect for people, assuming that individuals should be treated as autonomous and capable of deciding for themselves, and beneficence, defined as the duty to avoid harm and maximise possible benefits [29]. To ensure the respect of these principles, we recruited participants according to their willingness, and audio-recorded the interviews only with their consent, allowing the possibility to withdraw from the study at any time and to contact us after the interview for any further information. In order to preserve the anonymity of the participants, only their voices have been recorded even when interviews were conducted by video call. The interviews and their transcription were conducted by only one author (FM), who encrypted the sensitive information, with the aim of further ensuring the participants’ anonymity.

Results

The findings indicate that the main issue of giving birth during a pandemic was the uncertainty of the period, which seemed to be counterbalanced in some cases by the certainty of the loved ones’ support or, in other situations, emphasised by the loneliness associated with their absence. Therefore, our core category is “The certainty of the other in the uncertainty of the world”. The changes that occurred due to pregnancy and childbirth, added to the ones associated with the pandemic, were seen as a double upheaval in which healthcare personnel and loved ones, when present, were considered the main points of reference. The results also highlighted the importance of finding support in those who experienced the same situation and avoiding the intrusion of those who could not provide real support. In the next section, our five macro-categories are summarised and discussed. Fig. 1 illustrates our findings through a conceptual model of the psychosocial changes of giving birth during the Covid-19 pandemic. To preserve the participants’ anonymity, we reported, after each quotation, only the first letter of the interviewees’ name and the date of childbirth.

Fig. 1.

The certainty of the other in the uncertainty of the world: a conceptual model of the psychosocial changes of giving birth in the Covid-19 pandemic.

Macro-category 1. Giving birth in a pandemic as a double upheaval

The first macro-category concerns the double upheaval of giving birth during the Covid-19 pandemic. Our findings suggest that this upheaval was associated with the many changes imposed firstly by pregnancy and childbirth, which mainly represented desired changes, and secondly by the pandemic, which instead was considered to be a forced change. This macro-category involves the representation of Covid-19 uncertainty in a mother’s eyes, an issue that impacted the participant’s experiences, making Covid-19 a limit and an exacerbation of difficulties during the perinatal period. Such conditions led to experiencing several negative emotions, often faced by “looking at the bright side”.

Covid-19 uncertainty in a mother’s eyes

From the participants’ perspectives, giving birth during a pandemic was a challenging process characterised by concerns about the spread of the outbreak. In many cases, the idea that being infected is partly a matter of chance seemed to lead to a perception of uncertainty, especially in the early stages of the pandemic. Indeed, the higher risk of contagion characterising the first wave (March-May 2020) was associated, in our participants, with a sense of panic, enhanced by the rapid changes in security measures, the overabundance of media information, and low levels of perceived control over protecting themselves. The second wave of the pandemic (which began in mid-September 2020) was instead characterised by a higher sense of security associated with better knowledge of the virus and a sense of control of the contagion.

“It was at the very beginning of the pandemic, so we were all really panicked. There were no masks, and you didn’t really know what was going on […]. Now, in hindsight, it’s been nine months, so we know that if you walk around with your high-protection mask, gloves, etc., you are at least as protected as possible, and that healthcare workers test you for Covid, so you’re protected, but at the beginning, we didn’t know anything so […] I was in an absolute panic” (A., gave birth in August 2020).

Covid-19 as a limit and exacerbation of difficulties during the perinatal period

Covid-19 appears to have made the participants’ experiences of the perinatal period harder because of the concurrence of several negative factors, first of all, due to the practical limitations imposed by the emergency. The pandemic also represented an exacerbation of difficulties during pregnancy, childbirth, and post-partum, because Covid-19 was perceived as a further problem to worry about, along with all the other concerns normally related to perinatal experiences. Another frequently reported problem was the struggle to breastfeed due to the lack of information and practical support from an expert figure.

“I was prepared to try to breastfeed her, but there was no way, probably it would’ve been better if it happened at another time where you could request some obstetrician, someone who would even come to help” (V., gave birth in April 2020).

Among the main issues, there was the inability to take moments for oneself during the postpartum period, along with a general difficulty in accepting the disruption of lifestyle imposed simultaneously by lockdown, pregnancy, and birth.

“There was nothing normal anymore. […] I was already doing something that changed my life with the birth […]. And the birth of a child throws you into another world, then you think ‘I sought it, I wanted it, it’s a beautiful thing… but I didn’t ask for this other upheaval’. I mean. It was just an attempt to find some boundaries, and I couldn’t find them because everything was different from how I had left it” (V., gave birth in April 2020).

The negative emotions associated with giving birth during a pandemic

The uncertainty of the period was linked to harder birth experiences, described by negative emotions such as guilt for giving birth in a challenging moment. Other negative emotions reported were a sense of panic and anxiety, exacerbated by a lack of distractions, the absence of loved ones during the experience, and concerns for the impact of the pandemic on child development.

“Because you feel guilty and think: ‘Wow, I gave birth to him kind of at a bad time’. It’s like you feel guilty for giving birth to him in such a difficult time. You couldn’t even go on a simple walk. Since he was born in the summer, I already had the idea to go for walks with him, even though he was small. Instead, now it’s clear that he is not used to going out, […] when he comes home, he’s more serene. But unfortunately… it would have been nice to take walks, since it was summer, but unfortunately, we were forced at home… It was hard because that way you can relax, but if you stay at home 24/7, you become a little nervous” (L., gave birth in July 2020).

Looking at the bright side

One of the main adaptive coping strategies was to look at the bright side of the situation: during pregnancy, the quarantine represented a moment to rest, characterised by a positive atmosphere.

“At the beginning, the first impact with the pandemic wasn’t good at all. Anyway, we were able to move on. We went through the lockdown with a smile, mindful that this little baby was coming” (S., gave birth in October 2020).

During the postpartum, looking at the bright side meant considering the quarantine as a chance to better enjoy the first moments with the new-born, stay with family and process the birth in privacy. From the participants’ point of view, quarantine was also a precious opportunity for fathers, as they were able to be a constant and supportive presence for mothers, participating in the parenting life. Lastly, childbirth represented a reason to consider 2020 better than other people did.

“My family really feels this domestic dimension so much… right now we are all at home, my husband and I wake up, and every morning we bathe [our child] together, but who can currently afford this luxury? So yes, the situation is dramatic, it’s sad, but from this point of view, there is a positive aspect for me” (L., gave birth in October 2020).

Macro-category 2. Health professionals as a point of reference

In the second macro-category, the uncertainties of intrapartum care are described in the light of the relationship with health professionals. Despite the difficulties and discontinuities in the care pathway, the healthcare staff was the mothers’ main point of reference, allowing them to overcome the challenges they had to face.

The uncertainties of intrapartum care

The main uncertainties of intrapartum care included the access to medical examinations and the cancellation of antenatal classes, experienced as a missed opportunity to learn how to handle the fear of childbirth and the postpartum period, especially in cases of first pregnancy. Although in-person antenatal classes would have been preferred to the online ones, their presence was still perceived as better than their complete absence, which instead put women in a condition of uncertainty and anxiety. When antenatal classes were unavailable, obstetricians helped the women prepare themselves for the birth. Moreover, the regulations introduced to counter the emergency were perceived as limiting in relation to intrapartum care, sometimes preventing the timeliness of necessary treatments and the freedom of choice of pregnant women.

“I couldn’t do the nuchal translucency screening, the one that’s done to know whether the baby has Down Syndrome, because the appointment coincided exactly with the start of the first lockdown. I knew it was a very important medical examination for the baby, and I suffered a lot for not having done it. You never know until you find yourself in that situation, and I don’t know how I would have reacted. If there had been any anomalies I would’ve had, let’s say, the possibility to choose, but without that exam I couldn’t have it” (G., gave birth in October 2020).

In some cases, the women had to deal with the closing of the hospital of their choice, and they had to search, a few days before childbirth, for a new one that could take care of them, with the uncertainty of being accepted at the moment of birth due to the high number of requests.

“I had all the pregnancy check-ups done at the same hospital, so the medical staff knew me and my pregnancy history… A week before the planned date for delivery, the hospital closed as it turned into a Covid facility, so I found myself looking for a new hospital. It hasn’t been easy… Even though there were quite a few hospitals in my area, most were closed, except for the General Hospital and the one where I finally went for the delivery. Of course, since they were the only two wards available, all the pregnant women went there, and when I called, I was told: ‘Look, I am not sure whether we can examine you. If you think you are ready to give birth, just come in through the ER’. I mean, I understand that, but it was still a situation to keep a close eye on” (G., gave birth in March 2020).

The uncertainty of intrapartum care due to the closing of several hospitals has taken on the meaning of an interruption of the relationship with health professionals, who were considered highly valuable and necessary by the women interviewed. This situation, added to the obligation to be alone in the hospital and the need for human warmth, further enhanced by the pandemic, led to the perception of the hospital as a place of tension and loneliness, characterised by an unsettling atmosphere and described, in some cases, as a trap.

Trust and empathy for a good relationship with health professionals

Despite the pandemic, most women experienced a significant and empathic relationship with health professionals, especially obstetricians. The latter were the most cited figure among health professionals and appeared to be the main source of support.

“All obstetricians were great, both during and after childbirth. Being alone with the child, I could not handle everything, and as soon as you called them, they immediately came to the rescue, also because they said ‘Since it’s a peculiar period and you don’t even have a husband here to help you, we more than ever must be close to you, much more than before’ because we were basically alone” (M., gave birth in March 2020).

Macro-category 3. Loneliness and absence

The third macro-category concerns one of the main issues reported in the interviews: the theme of loneliness, referring to the loved ones’ absence during the perinatal period due to their exclusion, and in particular to the absence of the partner.

The unmet need to share

The absence of loved ones appeared to strongly influence the emotional aspect of the experience, leading to some important consequences such as the lack of emotional and practical support and the feeling of profound loneliness, especially during hospitalisation and postpartum.

“It’s a moment charged with emotions, worries, fears, and pain. It’s a unique moment, and in hindsight it’s a beautiful one, but you need someone to share it with… In our hospital, nobody was allowed to enter, so I spent my days mostly alone. You know, it’s tough. Besides, you experience frequent hormone imbalances, and you are not in your right mind during those days, and you feel like crying… but who do you cry with?” (A., gave birth in August 2020).

Participants often spontaneously reported what was the worst experience for them to go through alone: some of them described the hospitalisation as the worst aspect, others the physical difficulties, labour and delivery, and the medical examinations. More specifically, the missed chances to share some of the key experiences related to pregnancy (e.g., ultrasound scans, the discovery of the child’s sex, the first purchases for the unborn, etc.) with loved ones were associated with the perception of not having fully lived them. The main strategies used to fight loneliness included making video calls with loved ones, trying to distract oneself by thinking about something else, or preparing oneself in advance to be alone.

Exclusion of the partner as a missed chance to share feelings and responsibilities

The feeling of loneliness was associated with the partner’s absence, which was harder to bear during labour and delivery. His absence, which in hindsight made the memories of childbirth worse, assumed many significant meanings, such as the impossibility to benefit from his practical and emotional support, leading to the impossibility of sharing the emotions associated with childbirth. In addition, the partner’s practical exclusion led to the perception of his marginalisation on the level of emotions and decision-making, conveying the message that his role is secondary and ultimately leaving women alone to assume all responsibilities.

“Going to pregnancy check-ups together used to be ‘us’ time… Actually, when I was pregnant with my first child, after the check-ups, we used to go out and have dinner by ourselves. This time, not being able to do this routine, my husband joked, saying: ‘I don’t know this baby because I’ve never seen her’. Also, when they told me the baby was a girl, I had to tell him, but it wasn’t the same. You know, when you get the ultrasounds… It’s nice, it’s an emotional moment, hearing baby’s heartbeat and, also – banally or maybe not so – just talking to the doctor during a complicated pregnancy… I mean, I was handling that situation all by myself” (A., gave birth in August 2020).

Macro-category 4. The certainty of the presence of loved ones

While women who experienced their loved ones’ absence reported a sense of loneliness, in those who had the chance to experience their presence prevailed feelings of gratitude and the certainty of receiving support.

The luck of being able to share with loved ones

The chance to share one’s own experience with loved ones was generally interpreted as a fortune, more so in comparison with other women who could not benefit from such an opportunity.

“Luckily, I gave birth at a time when you could access the hospital because I heard of so many mothers who had to face everything alone, poor women” (D., gave birth in March 2020).

The presence of loved ones was experienced as a gesture of affection towards the pregnant woman, which positively influenced the recovery from childbirth and its memory. The reassuring and essential presence of someone who knows their needs was, for our participants, a source of huge emotional support.

“My parents were outside the ward when the baby was born, so I was aware that, no matter what, there was someone waiting for me” (N., gave birth in August 2020).

Partner involvement and parental engagement

Most of the time, the partner’s presence represented fundamental emotional and practical support, especially for pain management. In some cases, the partner played an active role in the birthing process, especially in couples that reported a representation of childbirth as a matter that concerns both members of the couple.

“The fact that my husband was there was the expression of how much this was and still is the idea of a common project” (L., gave birth in October 2020).

One of the main tasks for partners was to be the woman’s voice when she was unable to express herself due to pain or scant consideration by the healthcare staff, protecting her from eventual obstetric violence.

“Already during the pregnancy, I told him: ‘If you see that I can’t even breathe – because this is what happened to me with my first childbirth… I was alone, and I wasn’t able to express my needs, so I was completely at the mercy of the medics that under those circumstances can behave very well or maybe not so - you have to be my voice if I can’t get it out, so you need to know what I want to be done to me or not… you must be there and give me a hand’” (L., gave birth in October 2020).

Macro-category 5. Sharing the birth only with those who can understand

Besides those who are permanently configured as loved ones in the life of our participants (e.g., partners and parents), experiences related to the perinatal period are usually also shared with other supporting figures. It is interesting to note that the decision to share the experiences related to the birth seemed to depend on the specific ability of the other to support and empathise with the new mother. This ability, from our participants’ point of view, is particularly owned by the peer group, even in an online context, rather than by other people such as distant relatives or acquaintances. For this reason, the fifth and last macro-category consists of two categories: the first is related to peer sharing, whereas the second includes the feelings experienced in relation to the intrusion of those who cannot provide real support.

Sharing the birth with those who have experienced the same situation

Sharing the experience of becoming a mother in the pandemic era has made the peer group particularly suitable for seeking and providing emotional support.

“Fortunately, I did the prep course online, as they say… to make a virtue of necessity. So we adjusted, but online communication wasn’t bad at all. […] We’re still talking about the babies: ‘Is he crying? What’s he doing?’” (E., gave birth in October 2020).

Therefore, comparison, socialisation, and sharing with other mothers were key aspects of the experience. Participants addressed the peer group especially during the first pregnancy or in case of negative childbirth experiences.

The main chance to create a peer sharing group was represented by the online antenatal classes, attended in some cases more to socialise than to gather information. Furthermore, peer support online groups (e.g., Facebook groups) were used to compensate for the lack of in-presence socialisation, as well as to look for emotional and informational support and share negative birthing experiences.

“On Facebook, I found a group where I felt a little at home because they described their childbirth, with similar situations to mine, or worse. Not that it gave me relief, but I did not feel like I was the only one” (V., gave birth in April 2020).

Avoiding the intrusion of those who cannot provide real support

Sharing the birth event with those who cannot provide real support represented, for our participants, a source of negative emotions. A suitable example of such a situation is offered by the typical Italian custom of visiting the new mother immediately after childbirth. Such visits frequently involve not only loved ones but also distant relatives and friends, who often offer nothing more than apparent support. Interestingly, almost all women interviewed agreed that they did not want to receive these visits: indeed, they were considered to be an intrusion into the delicate period of reorganisation of family life with the newcomer. This was also due to the poorly tolerated condescension in the visitors’ comments, which increased the already great tension experienced by the mothers.

“For me, [the lockdown] was a godsend. I lived it well because I never wanted people at home… I used to say: ‘If you really want to visit me, come to the hospital and try not to dawdle there.’ So, honestly, I was very happy, despite this unfortunate situation, because I could enjoy the time with my daughter. There was no one there to tell me what to do and how, and it was best for me” (F., gave birth in March 2020).

For the majority, the pandemic and the quarantine were valid reasons to relieve themselves of this duty, reserving the possibility to receive guests only in the case of close relatives who could provide solid emotional and instrumental support.

“I appreciated the fact that there were no visits, and I think we should keep the stop to visits except for those who can help you out” (G., gave birth in March 2020).

Discussion

The current study explored the experiences of Italian women who gave birth during the pandemic, and how the changes imposed by Covid-19 impacted their psychosocial wellbeing.

Using a Grounded Theory approach, we highlighted that the main problem experienced by women in the perinatal period during the pandemic was uncertainty, which seems to be a problem not specific to the Italian context, as the same issue has also been highlighted by other studies carried out in different countries [13], [21], [30]. In the present study, the aforementioned uncertainty was mainly related to the many changes imposed by the pandemic and childbearing, which occurred at the same time, and specifically related to the limitations in intrapartum care (e.g., the cancellation of antenatal classes and medical appointments, the closing of hospitals, etc.) that worsened the difficulties of the perinatal period, limiting freedom of choice and continuity in intrapartum care.

Such conditions led to experiencing several negative emotions related to the great fear of getting infected, infecting the child, and not receiving adequate or timely intrapartum services. The fear of contagion seemed to enhance the uncertainty of the experience of becoming a mother in a pandemic, as also shown by Atmuri et al. [13]. Moreover, when speaking of negative feelings, another key emotion in the narratives collected was that of guilt, consistent with Chivers et al., [31]; in the present study, this feeling was often associated with the experience of giving birth to a child in an emergency situation. In such a situation, “looking at the bright side” was a common strategy to cope with this negative affective state.

In this frame of uncertainty, our results highlighted that social support is a crucial resource for psychosocial wellbeing, as was also well-highlighted by previous studies that considered the experience of becoming a mother during the Covid-19 pandemic [13], [32]. Presumably, its significance could also be further increased in the context of the pandemic, in which social support constituted a protective factor for mental wellbeing during pregnancy [16]. Our findings show that social support was mainly sought in partners and loved ones (e.g., parents, close relatives), in the healthcare staff, and in the peer network.

In particular, women who could not benefit from the support of loved ones experienced loneliness, while those who had this opportunity felt a great sense of gratitude. Moreover, the presence or absence of the other takes on different meanings. The presence of a “companion of choice” represented both protection from eventual mistreatment and the possibility of sharing responsibilities, as also demonstrated by some other studies on this issue [14], [30], [33]. Vice versa, their absence translated into the feeling of being at the mercy of the healthcare workers. This result is particularly significant when considering that the advent of the pandemic has increased the risk for obstetric violence [34]: in this perspective, the presence of a companion of choice could be considered an even more valuable protective factor against this threat. Furthermore, consistent with the literature [35], we found that being accompanied during intrapartum care was more than a chance to be supported: in some cases, partners, in particular, were considered in all respects as active actors in the birthing process.

Regarding the healthcare staff, most women looked for a point of reference in healthcare professionals, but only in those who were perceived as willing to offer it. Our results highlighted especially the critical role of the obstetricians, hypothetically enhanced by the increased need for human warmth, a central issue in our interviewees’ stories. From this perspective, the patient-obstetrician relationship was always evaluated as good, with the obstetricians representing an important point of reference, in line with Fumagalli et al. [23], who demonstrated that social support from the healthcare personnel, especially obstetricians, was a valid source of physical and psychosocial wellbeing.

Peer support was instead mainly sought through online platforms (e.g., Facebook groups), which can represent both important sources of information and meaningful means for sharing negative perinatal experiences, especially during the pandemic. These observations are in line with Charvat et al. [36], who highlighted the important role of online peer support groups in providing social support during pregnancy in the pandemic. Specifically, our participants used such online peer support groups as a source of emotional and informational support, especially to share their experience with people who they thought could understand them, due to the fact that they were facing the same situation.

The support received from peers seems to have partially compensated the participants’ (especially first-time mothers) concern for the cancellation of antenatal classes. When possible, online antenatal classes were provided, but the attendance of in-person antenatal classes would have been preferred. This finding is in line with the results of Atmuri et al. [13], who showed that, during Covid-19, in-person educational activities were preferred by pregnant women to online ones.

Although the emergency phase has now passed, understanding risks and protective factors that define the balance of women’s psychosocial wellbeing during the perinatal period remains an issue of fundamental importance, in order to provide evidence-based data that can guide better management of epidemics and pandemic situations in the future.

Limitations

There are several limitations to this study. First, our findings referred in particular to the experiences that occurred between March and November 2020, when pregnancy regulations and procedures in response to the Covid-19 emergency were still unclear [2]. Indeed, in the early stages of the pandemic, the main concerns were related to the lack of knowledge about Covid-19 prevention and treatments, and about the possible negative impact of the virus on pregnant women’s conditions [4]. Currently, women’s concerns and needs may have changed in the light of the clearer hospital procedures, although, in Italy, the latter may still partially vary from hospital to hospital [2]. Moreover, from a psychological point of view, it is plausible to imagine that women’s fears – at least those related to the effects of the virus – may have been allayed due to the introduction of the vaccine. However, this hypothesis is still to be explored, given the widespread Covid-19 vaccine hesitancy affecting many groups of the population [37].

Future directions

Although the emergency phase has been overcome and the pandemic situation is relatively under control also due to the beginning of the vaccination campaign [38], we are still a long way from pre-pandemic conditions. Since our results are focused on a specific stage of the pandemic, it is important to understand if and how the key experiences and psychosocial changes reported by our participants (i.e., the feeling of uncertainty and the need for social support) are still present late in the pandemic and what their eventual impact would be on mothers’ psychosocial wellbeing. However, our results highlight the potential of online resources as a tool for social support (i.e., Facebook peer groups and online antenatal classes); thus, this research could represent the starting point for future studies to test the efficacy of health promotion interventions based on this kind of social support. Moreover, future studies would benefit from further investigating the impact of the pandemic on specific perinatal experiences that emerged from our participants’ interviews, such as the intention to breastfeed, which can be linked to several health benefits for mothers and new-borns [39]. Finally, it can be of further interest to understand how fathers experienced being excluded from delivery rooms and intrapartum care in general.

Conclusions

The present study showed that the Covid-19 pandemic affected the psychosocial wellbeing of Italian women in the perinatal period in many ways. One of the main issues was the discontinuity in intrapartum care, which filled the perinatal period with uncertainties and negative emotions. In this situation, a crucial factor was represented by the presence or absence of social support, sought in loved ones, health professionals, and peer groups, in line with several studies on the same subject [13], [36]. In general, we could conclude that the lack of social support was related to a more stressful perinatal experience, which suggests the importance of paying attention to its decrease during the pandemic [40]. On the other hand, its presence was one of the main protective factors against negative mental health outcomes [32]. Considering in particular the partners’ involvement, sharing the experiences of the perinatal period meant much more than being supported; it represented, above all, a chance to share responsibilities [13], [30]. These results can inform evidence-based policies and interventions aimed at promoting women’s psychosocial wellbeing in the perinatal period – policies that should also consider social support as a central element. Interventions should focus primarily on the power of peer groups and health care personnel, which were essential sources of psychosocial support, in addition to loved ones. Furthermore, policies and health actions should be implemented to guarantee continuity in intrapartum care, particularly concerning the presence of loved ones during key perinatal experiences.

Grant support information

No funding involved.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethical Committee of Psychological Research of the Department of Humanities of the University of Naples Federico II and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.