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. 2023 Jan 10;27(2):335–345. doi: 10.1007/s10995-022-03578-0

Psychosocial Stressors and Maternal Mental Health in the U.S. During the First Wave of the COVID-19 Pandemic: A Cross-Sectional Analysis

Angela M Parcesepe 1,2,✉, Sarah G Kulkarni 3, Christian Grov 3,4, Rebecca Zimba 3, William You 3, Drew A Westmoreland 3, Amanda Berry 3, Shivani Kochhar 3, Madhura S Rane 3, Chloe Mirzayi 3,5, Andrew R Maroko 3,6, Denis Nash 3,5
PMCID: PMC9838406  PMID: 36625954

Abstract

Objectives

The COVID pandemic has had widespread impacts on maternal mental health. This research aims to examine the relationship between psychosocial stressors and symptoms of depression and anxiety and the extent to which emotional support or resilient coping moderates the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID pandemic.

Methods

This analysis includes data collected in October and November 2020 from a geographically and sociodemographically diverse sample of 776 mothers in the U.S. with children ≤ 18 years of age. Log binomial models were used to estimate the association between moderate or severe symptoms of anxiety and depression and psychosocial stressors.

Results

Symptoms of moderate or severe anxiety and depression were reported by 37.5% and 37.6% of participants, respectively. Moderate (aRR 2.76 [95% CI 1.87, 4.07]) and high (aRR 4.95 [95% CI 3.40, 7.20]) levels of perceived stress were associated with greater risk of moderate or severe anxiety symptoms. Moderate and high levels of parental burnout were also associated with greater prevalence of moderate or severe anxiety symptoms in multivariable models. Results were similar when examining the relationship among stress, parental burnout, and depressive symptoms. Neither resilient coping nor social support modified the relationship between psychosocial stressors and mental health.

Conclusions for Practice

Evidence-based strategies to reduce stress and parental burnout and improve the mental health of mothers are urgently needed. Strategies focused on bolstering coping and social support may be insufficient to improve maternal mental health during acute public health emergencies.

Keywords: Maternal, Mental health, COVID, Stress, Burnout

Significance

The COVID pandemic has had widespread impacts on maternal mental health. Less is known about potentially modifiable factors that may bolster mental health during public health emergencies. This article assessed the relationship between psychosocial stressors and symptoms of anxiety and depression among mothers in the U.S. during the first wave of the COVID-19 pandemic and the extent to which emotional support or resilient coping moderated the relationship between psychosocial stressors and maternal mental health. Coping-focused interventions or strategies to increase social support may be insufficient to bolster mental health during the acute phase of public health emergencies.

Introduction

Mental health disorders are among the leading causes of disability worldwide and have been consistently associated with poor physical health and economic outcomes (Friedrich, 2017; Mathers & Loncar, 2006). Maternal depression and anxiety are highly prevalent and have also been associated with worse health, developmental, and behavioral outcomes among children (Friedrich, 2017; Rahman et al., 2013). Addressing maternal mental health has the potential to improve the physical and mental health of mothers and their children (Rahman et al., 2013).

The COVID-19 pandemic has increased the prevalence of mental health disorders in the US (Czeisler et al., 2020; Jia et al., 2021; Kessler et al., 2022; Vahratian et al., 2021). More specifically, the prevalence of anxiety and depressive symptoms among US adults increased significantly during the COVID pandemic and has remained elevated (Jia et al., 2021). Depression and anxiety have been exacerbated during the COVID-19 pandemic due to physical distancing restrictions, increased material hardship, decreased social support, concerns about COVID-19 exposure, directly experiencing COVID, and disruption to mental health services (Amsalem et al., 2021; Fang et al., 2021; Holmes et al., 2020; Lee et al., 2021; Peitzmeier et al., 2021). The prevalence of unmet mental health care needs has also increased (Vahratian et al., 2021).

Similar to findings with the general US population, the COVID-19 pandemic has also had widespread impacts on maternal mental health (Bottemanne et al., 2021; Chmielewska et al., 2021; Hessami et al., 2022). Increased prevalence of anxiety and depression has been documented among US mothers during the COVID-19 pandemic (Bottemanne et al., 2021; Hessami et al., 2022).

A number of psychosocial factors have been consistently associated with poor maternal mental health, including stress, material hardship, and parental burnout (Biaggi et al., 2016; Heflin & Iceland, 2009; Maynard et al., 2018). The COVID-19 pandemic has dramatically changed the landscape of work and family arrangements in unprecedented ways throughout the United States. During the first wave of the pandemic, non-pharmaceutical interventions, such as physical distancing, were widely implemented to reduce the transmission of COVID-19. Schools and childcare facilities closed or transitioned to remote learning, and teleworking among non-essential workers became widespread. The direct and indirect impacts of the COVID-19 pandemic have led to increased psychosocial stressors for U.S. families. For example, material hardship including unemployment, lost wages, food insecurity, and housing insecurity has increased throughout the U.S during the COVID-19 pandemic (Fang et al., 2022; Linton et al., 2021; United States Department of Labor, 2020). In addition, for many families, remote schooling and shuttered childcare facilities have led to increased caregiving burden and significant challenges balancing work and family responsibilities. Unemployment has disproportionately impacted women during the pandemic, due in part to increased childcare responsibilities (Dang & Viet Nguyen, 2021). In fact, the U.S. Bureau of Labor Statistics estimated that 2 million fewer women were participating in the U.S. labor force in October 2020 compared to October 2019. Disruptions to daily schedules combined with the chronic stress and uncertainty of the COVID-19 pandemic may result in increased parental burnout among U.S. mothers (Griffith, 2022; Griffith et al., 2022; Kerr et al., 2021). Parental burnout has been defined as “a prolonged response to chronic and overwhelming parental stress” and is often accompanied by physical and mental health symptoms (Mikolajczak et al., 2019; Prikhidko et al., 2020).

Social support and resilient coping have been positively associated with mental health (Santini et al., 2015; Wang et al., 2018). Social support may directly influence mental health through beneficial effects of social relationships and indirectly through buffering the impact of stressful circumstances or adversity. Similarly, resilience, a multidimensional construct, commonly conceptualized as one’s ability to cope adaptively to stressful life events, may moderate the relationship between stress and mental health (Connor & Davidson, 2003; Sinclair et al., 2016).

Greater understanding of the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID-19 pandemic as well as potentially modifiable moderators of this relationship can inform the adaptation or development and targeting of evidence-based interventions that can be digitally delivered during future public health emergencies. This research aims to: (1) examine the relationship between two forms of psychosocial stress (perceived stress and parental burnout) and symptoms of depression and anxiety; and (2) examine to what extent emotional support or resilient coping moderates the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID pandemic.

While it has been widely established that the COVID pandemic has had significant negative impacts on mental health among both the general population and mothers in the US, this research seeks to advance the literature in several important ways. First, most research on maternal mental health during the COVID-19 pandemic has focused on maternal health during pregnancy or while parenting infants or young children (Farrell et al., 2020; Hessami et al., 2022; Kotlar et al., 2021; Yan et al., 2020). Less is known about the impact of the COVID-19 pandemic on mental health of mothers parenting older children. In addition, research that includes parents of older children is often not disaggregated by parent gender, limiting conclusions that can be drawn from this research about maternal mental health specifically (Czeisler et al., 2021).

Second, this work moves beyond estimating the prevalence of symptoms of anxiety and depression which has been widely documented in the literature and examines the relationship between modifiable stressors and protective factors of maternal mental health. Greater understanding of modifiable factors associated with maternal mental health during the first wave of the COVID pandemic can inform promising strategies to bolster maternal mental health during future acute public health emergencies. Further, the frequency and severity of public health emergencies, including epidemics, natural disasters, and conflict, has increased over the last several decades. By situating this research during the first phase of the COVID pandemic, this research has particular salience for the development of pandemic preparedness strategies to support maternal mental health during future pandemics or other public health emergencies.

Methods

Data Source and Population

The CHASING COVID Cohort study is a geographically and sociodemographically diverse sample of adults (18 and older), residing in the U.S. or U.S. territories who enrolled into a prospective cohort study during the emergence of the COVID-19 pandemic in the U.S. (Robertson et al., 2021). Details of cohort recruitment and follow-up have been described elsewhere (Robertson et al., 2021). Briefly, internet-based strategies were used to recruit a fully online cohort. Study participants were recruited from March to April 2020 via advertisements on various social media platforms (e.g., Facebook) or via referral (anyone with knowledge of the study was allowed to invite others to participate). CHASING COVID Study Participants who were parents of children aged 18 or younger and identified as female, non-binary, or gender-nonconforming were invited by email to complete a follow-up online assessment focused on parenting, mental health, psychosocial stressors, social support, and coping. Data collection for the follow up parenting survey occurred in October and November 2020. The study protocol was approved by the Institutional Review Board at City University of New York. Sociodemographic and material hardship data for the current analysis were collected between March and April 2020 as part of the baseline CHASING COVID Study Cohort assessment. All other data in the current analysis were collected between October and November 2020 as part of a follow-up survey of CHASING COVID Study Cohort participants focused on parenting and mental health.

Measures

Depressive Symptoms

Depressive symptoms were assessed with the Patient Health Questionnaire-8 (PHQ-8), an 8-item screener that assesses the presence of depressive symptoms within the last 2 weeks (Kroenke et al., 2009). Scores of 10 or greater are commonly considered as an indication of moderate or severe depressive symptoms.

Anxiety Symptoms

Anxiety symptoms were assessed with the General Anxiety Disorder-7 (GAD-7) a 7-item screener that assesses the presence of anxiety symptoms within the past 2 weeks (Spitzer et al., 2006). Scores of 10 or greater are commonly considered as an indication of moderate or severe anxiety symptoms.

Perceived Stress

Perceived stress was assessed using the Perceived Stress Scale-4 item (PSS-4) which assesses perceptions of global stress in the past month (Cohen, 1983). Two items were recoded so that higher scores on all items indicated more stress. Responses were summed and categorized into tertiles.

Parental Burnout

Parental burnout was assessed using four items from the Parental Burnout Inventory that asked, since the coronavirus pandemic began, how often have you felt: emotionally drained by your role as a parent; as though you are taking care of your children on autopilot; tired when you get up in the morning and have to face another day with your children; and at the end of your patience at the end of a day with your children. Response options were: never, once a month or less, a few times a month, a few times a week, and every day (Roskam et al., 2017). Higher responses indicated more parental burnout. Responses were summed and categorized into tertiles.

Emotional Support

Perceived emotional support was assessed using a 4-item scale developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) (Cella et al., 2010). Response options included: never, rarely, sometimes, often or always. Responses were summed and categorized into tertiles.

Resilient Coping

Resilient coping was assessed using the Brief Resilient Coping Scale (BRCS), a 4-item scale that measures capacity to respond to stress in an adaptive way (Sinclair & Wallston, 2004). Higher scores indicated greater resilient coping. Scores were summed and categorized into tertiles.

Significant Income loss

Participants were asked if they had experienced a significant personal loss of income as a result of the COVID-19 pandemic.

Food Insecurity

Individuals were asked whether two statements were often, sometimes, or never true for their households in the past month: “We couldn’t afford to eat balanced meals” and “The food we bought just didn’t last, and we didn’t have money to get more.” Individuals who responded that both statements were never true were categorized as not having experienced food insecurity.

Housing Insecurity

Individuals were asked how worried or stressed they were in the past month about having enough money to pay their rent or mortgage. Response options included: always, usually, sometimes, rarely, and never.

Sociodemographics

Participants were asked to report their gender, age, race/ethnicity, income, employment status, and number and age of their children.

Analysis

Univariate analyses were conducted to assess the prevalence of anxiety and depressive symptoms. Associations between psychosocial factors (perceived stress, parental burnout, emotional support, and resilient coping) and anxiety and depressive symptoms were analyzed using Pearson chi-squared tests. Log binomial models were used to generate risk ratios to assess the relationship between anxiety and depressive symptoms and psychosocial factors. Adjusted analyses controlled a priori for age, race/ethnicity, and housing insecurity. Because psychosocial factors assessed were correlated with each other, separate regression models were run for each psychosocial factor.

We also examined whether the association between anxiety or depressive symptoms and stressors (perceived stress or parental burnout) was modified by emotional support or resilient coping. First, the magnitude and statistical significance of product terms between stressors (perceived stress and parental burnout) and potential modifiers (emotional support and resilient coping) were examined. Effect modification was also assessed visually by plotting mean anxiety and depression scores at each tertile of perceived stress and parental burnout, stratified first by tertiles of emotional support, and then by tertiles of resilient coping.

Results

A total of 1,486 individuals enrolled in the CHASING COVID Cohort Study were invited for participation in the current survey. Of those, 863 indicated interest and were screened for eligibility. A total of 787 individuals were eligible and completed the survey. Of those, 11 identified as transgender, non-binary, or gender-nonconforming. Because the mental health of transgender, non-binary, or gender-nonconforming parents may be meaningfully different than the mental health of cisgender parents and because our sample size was insufficient to examine parental mental health disaggregated by gender identity, the current analysis is limited to female cisgender parents. The current study reports on the 776 cisgender female parents of children 18 or younger for whom data on anxiety and depression were available. A total of 37.5% reported moderate or severe anxiety symptoms and 37.6% reported moderate or severe depressive symptoms, with 30.2% reporting moderate or severe symptoms of both anxiety and depression in October or November 2020 (Table 1). Overall, 42.4% of respondents were between 30 and 39 years of age (Table 2). Just over half (51.1%) identified as non-Hispanic White and 23.3% identified as Hispanic.

Table 1.

Mental health symptoms of U.S. mothers of children ≤ 18 during the COVID pandemic

Anxiety symptoms
n = 776
n (%)		 Depressive symptoms n = 776
n (%)
None (0–4) 221 (28.5) 240 (30.9)
Mild (5–9) 264 (34.0) 244 (31.4)
Moderate (10–14) 162 (20.9) 155 (20.0)
Severe (15+) 129 (16.6) 137 (17.6)
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Table 2.

Sociodemographic Characteristics and Anxiety and Depressive Symptoms among mothers in the U.S. during the COVID-19 pandemic

Anxiety Symptoms Depressive symptoms
Total
n = 776
n (%)		 None/Mild
n = 485
n (%)		 Moderate/Severe
n = 291
n (%)		 p-value None/mild
n = 484
n (%)		 Moderate/Severe
n = 292
n (%)		 p-value
Age 0.70 0.05
 18–29 137 (17.7) 80 (58.4) 57 (41.6) 76 (55.5) 61 (44.5)
 30–39 329 (42.4) 208 (63.2) 121 (36.8) 199 (60.5) 130 (39.5)
 40–49 223 (28.7) 140 (62.8) 83 (37.2) 154 (69.1) 69 (30.9)
 50+ 87 (11.2) 57 (65.5) 30 (34.5) 55 (63.2) 32 (36.8)
Race/ethnicity
 Hispanic 181 (23.3) 114 (63.0) 67 (37.0) 0.01 114 (63.0) 67 (37.0) 0.07
 Non-Hispanic White 397 (51.1) 236 (59.4) 161 (40.5) 245 (61.7) 152 (38.3)
 Non-Hispanic Black 102 (13.1) 64 (62.7) 38 (37.3) 63 (61.8) 39 (38.2)
 Asian/Pacific Islander 66 (8.5) 54 (81.8) 12 (18.2) 49 (74.2) 17 (25.8)
 Other 30 (3.9) 17 (56.7) 13 (43.3) 13 (43.3) 17 (56.7)
Income ($) < 0.0001 < 0.0001
 < 50,000 299 (39.4) 156 (52.2) 143 (47.8) 151 (50.5) 148 (49.5)
 50,000–99,999 224 (29.5) 148 (66.1) 76 (33.9) 143 (63.8) 81 (36.2)
 100,000+ 236 (31.1) 167 (70.8) 69 (29.2) 178 (75.4) 58 (24.6)
 Missing 17
Employment status 0.004 0.0001
 Employed 508 (65.6) 330 (65.0) 178 (35.0) 332 (65.4) 176 (34.6)
 Out of work 86 (11.1) 41 (47.7) 45 (52.3) 39 (45.4) 47 (54.6)
 Homemaker 148 (19.1) 99 (66.9) 49 (33.1) 99 (66.9) 49 (33.1)
 Student 15 (1.9) 6 (40.0) 9 (60.0) 4 (26.7) 11 (73.3)
 Retired/Other 19 (2.5) 9 (47.4) 10 (52.6) 10 (52.6) 9 (47.4)
Essential worker 0.66 0.30
 Yes 102 (14.2) 63 (61.8) 39 (38.2) 60 (58.8) 42 (41.2)
 No 616 (85.8) 394 (64.0) 222 (36.0) 395 (64.1) 221 (35.9)
 Missing 58
Mean # children 1.86 1.86 1.86 1.85 1.90
Age of youngest child
 0–4 257 (33.1) 152 (59.1) 105 (40.9) 0.36 161 (62.6) 96 (37.4) 0.86
 5–12 318 (41.0) 208 (65.4) 110 (34.6) 195 (61.3) 123 (38.7)
 13–18 201 (25.9) 125 (62.2) 76 (37.8) 128 (63.7) 73 (36.3)
Child schooling format
 Children too young to attend school 98 (14.6) 65 (66.3) 33 (33.7) 0.99 66 (67.3) 32 (32.7) 0.86
 All school-age children attended school remotely from home 327 (48.7) 211 (64.5) 116 (35.5) 209 (63.9) 118 (36.1)
 All school-age children attended school in person 120 (17.9) 78 (65.0) 42 (35.0) 73 (60.8) 47 (39.2)
 All school-age children attended a hybrid model 84 (12.5) 54 (64.3) 30 (35.7) 55 (65.5) 29 (34.5)
 Some school-age children attended in person and some attended remotely 43 (6.4) 28 (65.1) 15 (34.9) 29 (67.4) 14 (32.6)
 Missing 104
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Material hardship was commonly reported (Table 3). Over half (53.4%) reported significant income loss during the pandemic. Over one-third (39.4%) reported food insecurity in the past month and 23.8% reported being often or always worried about housing expenses in the past month. All measures of material hardship were associated with symptoms of depression and anxiety.

Table 3.

Psychosocial stressors and mental health among mothers in the U.S. during the COVID-19 pandemic

Anxiety Symptoms Depressive symptoms
Total sample
n = 776
n (%)		 None/Mild
n = 485
n (%)		 Moderate/Severe
n = 291
n (%)		 p-value None/mild
n = 484
n (%)		 Moderate/Severe
n = 292
n (%)		 p-value
Recent food insecurity < 0.0001 < 0.0001
 No 435 (60.6) 313 (71.9) 122 (28.1) 311 (71.5) 124 (28.5)
 Yes 283 (39.4) 144 (50.9) 139 (49.1) 144 (50.9) 139 (49.1)
 Missing 58
Recent housing insecurity < 0.0001 < 0.0001
 Never 232 (32.3) 181 (78.0) 51 (22.0) 176 (75.9) 56 (24.1)
 Rarely/Sometimes 315 (43.9) 201 (63.8) 114 (36.2) 207 (65.7) 108 (34.3)
 Often/Always 171 (23.8) 75 (43.9) 96 (56.1) 72 (42.1) 99 (57.9)
 Missing 58
Significant income loss during pandemic
 No 319 (46.6) 231 (72.4) 88 (27.6) < 0.0001 231 (72.4) 88 (27.6) < 0.0001
 Yes 366 (53.4) 193 (52.7) 173 (47.3) 195 (53.3) 171 (46.7)
 Missing 91
Perceived stress
 Low (0–6) 256 (33.0) 226 (88.3) 30 (11.7) < 0.0001 219 (85.6) 37 (14.4) < 0.0001
 Moderate (7–8) 263 (33.9) 172 (65.4) 91 (34.6) 172 (65.4) 91 (34.6)
 High (9–16) 256 (33.0) 86 (33.6) 170 (66.4) 92 (35.9) 164 (64.1)
 Mean score (0–16) 7.51 6.39 9.38 6.44 9.27
 Missing 1
Parental burnout
 Low (0–7) 249 (32.2) 204 (81.9) 45 (18.1) < 0.0001 196 (78.7) 53 (21.3) < 0.0001
 Moderate (8–13) 244 (31.5) 164 (67.2) 80 (32.8) 164 (67.2) 80 (32.8)
 High (14–20) 281 (36.3) 116 (41.3) 165 (58.7) 122 (43.4) 159 (56.6)
 Mean score (0–20) 10.62 9.05 13.24 9.20 12.92
 Missing 2
Emotional support
 Low (0–9) 258 (33.3) 124 (48.1) 134 (51.9) < 0.0001 112 (43.4) 146 (56.6) < 0.0001
 Moderate (10–14) 268 (34.5) 176 (65.7) 92 (34.3) 180 (67.2) 88 (32.8)
 High (15–16) 250 (32.2) 185 (74.0) 65 (26.0) 192 (76.8) 58 (23.2)
 Mean score (0–16) 11.39 12.27 9.91 12.50 9.55
Resilient coping
 Low (0–9) 243 (31.3) 122 (50.2) 121 (49.8) < 0.0001 123 (50.6) 120 (49.4) < 0.0001
 Moderate (10–12) 332 (42.8) 226 (68.1) 106 (31.9) 227 (68.4) 105 (31.6)
 High (13–16) 201 (25.9) 137 (68.2) 64 (31.8) 134 (66.7) 67 (33.3)
 Mean score (0–16) 10.86 11.23 10.25 11.19 10.33
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Perceived stress and parental burnout were positively associated with symptoms of anxiety and depression. Specifically, the prevalence of moderate or severe anxiety symptoms was 11.7%, 34.6%, and 66.4% among those with low, moderate, and high levels of perceived stress, respectively, and 18.1%, 32.8%, and 58.7% among those with low, moderate, and high levels of parental burnout, respectively. Similar patterns were observed for the relationship among depressive symptoms, perceived stress, and parental burnout. Emotional support was inversely related to symptoms of depression and anxiety. The prevalence of moderate or severe anxiety symptoms among those with low, moderate, or high levels of resilient coping was 49.8%, 31.9%, and 31.8%, respectively. A similar pattern was observed between depressive symptoms and resilient coping.

Moderate and high levels of stress were associated with greater risk of symptoms of moderate or high levels of anxiety and depression across all models. Specifically, in multivariable models, moderate and high levels of perceived stress were associated with greater risk of moderate to severe anxiety symptoms (moderate stressvs. low: aRR 2.8 [95% CI 1.9, 4.1]); high stressvs. low: aRR 4.9 [95% CI 3.4, 7.2]) (Table 4). Moderate and high levels of stress were associated with greater risk of moderate or high levels of depressive symptoms (moderate stress vs. low aRR 2.3 [95% CI 1.6, 3.2]; high stress vs. low: aRR 3.8 [95% CI 2.7, 5.3]). Moderate and high levels of parental burnout were associated with greater risk of moderate to severe symptoms of anxiety (moderate parental burnout vs. low: aRR 1.3 [95% CI 1.0, 1.6]; high parental burnout vs. low: aRR 1.9 [95% CI 1.6, 2.3]). In adjusted models, compared to low parental burnout, moderate parental burnout was associated with 1.1 (95% CI 1.0, 1.2) times the risk of moderate to severe depressive symptoms and high parental burnout was associated with 1.3 (95% CI 1.1, 1.4) times the risk of moderate to severe depressive symptoms.

Table 4.

Bivariate and multivariable analyses of perceived stress, parental burnout, and symptoms of anxiety and depression

Anxiety Depression
RR (95% CI) aRR (95% CI)a RR (95% CI) aRR (95% CI)a
Perceived stress
 Low 1.00 1.00 1.00 1.00
 Moderate 2.98 (2.05, 4.33) 2.76 (1.87, 4.07) 2.38 (1.69, 3.34) 2.26 (1.59, 3.23)
 High 5.69 (4.02, 8.05) 4.95 (3.40, 7.20) 4.47 (3.28, 6.11) 3.75 (2.67, 5.26)
Parental burnout
 Low 1.00
 Moderate 1.80 (1.31, 2.48) 1.31 (1.04, 1.64) 1.55 (1.15, 2.09) 1.10 (1.00, 1.21)
 High 3.30 (2.49, 4.37) 1.90 (1.55, 2.32) 2.67 (2.06, 3.46) 1.25 (1.14, 1.37)
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aAdjusted for age, race/ethnicity, and housing insecurity; separate models run for perceived stress and parental burnout

When adjusted for age, race/ethnicity, housing insecurity, and parental burnout, moderate and high levels of emotional support were associated with lower risk of moderate to severe anxiety symptoms (moderate support vs. low: aRR 0.8 [95% CI 0.6, 0.9]; high support vs. low: aRR 0.6 [95% CI 0.5, 0.8]) (Table 5). Moderate and high levels of resilient coping were associated with lower risk of moderate to severe anxiety symptoms, after adjusting for age, race/ethnicity, housing insecurity, and parental burnout (moderate resilient coping vs. low: aRR 0.7 [95% CI 0.6, 0.9]; high resilient coping vs. low: aRR 0.7 [95% CI 065, 0.9]). Similarly, moderate and high levels of resilient coping were associated with lower risk of moderate to severe depressive symptoms, after adjusting for age, race/ethnicity, housing insecurity, and parental burnout (moderate resilient coping vs. low: aRR 0.7 [95% CI 0.6, 0.8]; high resilient coping vs. low: aRR 0.8 [95% CI 0.6, 1.0]).

Table 5.

Bivariate and multivariable analyses of emotional support, resilient coping, and symptoms of anxiety and depression

Anxiety Depression
RR (95% CI) aRR (95% CI)a aRR (95% CI)b RR (95% CI) aRR (95% CI)a aRR (95% CI)b
Emotional support
 Low 1.00
 Moderate 0.68 (0.56, 0.83) 0.80 (0.68, 0.95) 0.75 (0.64, 0.89) 0.59 (0.48, 0.71) 0.69 (0.58, 0.83) 0.72 (0.62, 0.85)
 High 0.50 (0.40, 0.64) 0.88 (0.71, 1.09) 0.62 (0.50, 0.77) 0.40 (0.31, 0.52) 0.63 (0.50, 0.81) 0.60 (0.49, 0.73)
Resilient coping
 Low 1.00 1.00
 Moderate 0.66 (0.54, 0.80) 0.73 (0.62, 0.86) 0.72 (0.60, 0.86) 0.64 (0.52, 0.78) 0.71 (0.59, 0.84) 0.70 (0.56, 0.84)
 High 0.65 (0.52, 0.83) 0.87 (0.72, 1.04) 0.75 (0.61, 0.92) 0.67 (0.53, 0.84) 0.87 (0.72, 1.05) 0.77 (0.62, 0.96)
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Separate models run for emotional support and resilient coping

aAdjusted for age, race/ethnicity, housing insecurity, and perceived stress

bAdjusted for age, race/ethnicity, housing insecurity, and parental burnout

When examined visually, neither emotional support nor resilient coping appeared to modify the relationship between perceived stress and anxiety or depression or the relationship between parental burnout and anxiety or depression. Similarly, there were no statistically significant interactions at the p < 0.10 level of significance.

Discussion

Symptoms of depression and anxiety were commonly reported among this sample of U.S. mothers with children 18 years or younger during the COVID-19 pandemic. Overall, symptoms of moderate to severe anxiety and depression were reported by 37% and 38% of participants, respectively. Perceived stress was significantly associated with greater prevalence of symptoms of maternal depression and anxiety. This is consistent with previous research that has found stress to be associated with poor mental health (Hammen, 2005; Kendler et al., 2000; Schneiderman et al., 2005). The early phase of the COVID pandemic created a situation of chronic stress for many parents (Omaleki et al., 2022). Strategies to reduce individual- and family-level stressors are needed and may be particularly beneficial during the acute phase of public health emergencies (Fong & Iarocci, 2020; Omaleki et al., 2022). Paid family leave, affordable and accessible childcare, and basic universal income should be considered as structural interventions that may reduce stress and improve the health and well-being of families. The impact of such policies on maternal mental health warrants rigorous investigation, particularly as the mental health impact of policy- or structural-level interventions, including paid family leave, remains poorly understood (Aitken et al., 2015). The availability and reach of telehealth mental health services, including app-based mental health care, increased substantially throughout the pandemic (AlRasheed et al., 2022; Cantor et al., 2022; Farrer et al., 2022). Individual-level interventions with demonstrated effectiveness at reducing stress and improving symptoms of depression and anxiety, such as cognitive-behavioral therapy and mindfulness-based stress reduction, could be expanded and delivered in targeted fashion via digital platforms during acute public health emergencies as well as incorporated into routine care platforms (Cuthbert et al., 2022; Witarto et al., 2022).

Moderate to high levels of parental burnout was associated with greater prevalence of moderate to severe symptoms of maternal depression and anxiety. One explanatory theory of parental burnout posits that burnout results from a persistent mismatch between parenting-related demands or expectations and mental or emotional resources available to meet these demands (Holly et al., 2019; Mikolajczak & Roskam, 2018). As schools and childcare facilities closed or transitioned to remote learning in the first wave of the COVID pandemic, many mothers faced substantially increased caregiving burdens at a time when other responsibilities persisted or increased (Griffith et al., 2022; Skjerdingstad et al., 2022). The strain of caregiving during the first wave of the pandemic, continued demands of work and other responsibilities, and concerns for the health of loved ones created situations in which parenting-related demands consistently exceeded available resources within many families (Griffith et al., 2022). Research into strategies to reduce parental burnout during acute public health emergencies is warranted. While little remains known about the effectiveness of strategies to reduce parental burnout, individual- and family-based strategies to reduce parenting-related stress and caregiver burden should be considered and their effectiveness at reducing parental burnout and improving maternal mental health investigated.

Emotional support and resilient coping were inversely associated with depression and anxiety among the current sample of mothers in the U.S. during the first wave of the COVID-19 pandemic. Previous research has similarly found greater social support to be inversely related to poor mental health (Wang et al., 2018; Werner-Seidler et al., 2017). Neither emotional support nor resilient coping modified the relationship between stress or burnout and symptoms of depression or anxiety. As such, strategies focused exclusively or primarily on enhancing emotional support or resilient coping may be inadequate to address maternal mental health needs during future public health emergencies.

Our findings should be understood in light of their limitations. Although our sample is national in scope and geographically and sociodemographically diverse, it was not designed to provide estimates that are representative of the US population of mothers of children 18 years or younger in the U.S. Second, the directionality or temporal order of relationships reported cannot be ascertained, and measures were self-reported. In addition, it is possible that individuals most burdened by caretaking or mental health symptoms were less likely to participate compared to individuals with fewer caretaking burdens or mental health symptoms. Further, we do not have information about how our sample compares to those who were eligible but chose not to enroll in this study. Finally, this study focused on the experiences of female cisgender parents in the U.S. The mental health of fathers and transgender, nonbinary, and gender-nonconforming parents in the U.S. warrants attention.

Symptoms of depression and anxiety were commonly reported among this sample of mothers of children 18 years or younger in the U.S. during the first wave of the COVID pandemic and positively associated with stress, material hardship, and parental burnout. Strategies to improve maternal mental health during future public health emergencies should consider mechanisms to reduce or manage stress. Mothers who endorse moderate or high levels of stress or parental burnout should be targeted for mental health screening and referral to care, where indicated. Given high levels of comorbid depression and anxiety, transdiagnostic approaches which are designed to address common elements of both disorders may be particularly relevant. Coping-focused interventions or interventions to increase social support may be insufficient to bolster maternal mental health during acute public health emergencies.

Funding

Funding for this project is provided by the CUNY Institute for Implementation Science in Population Health (cunyisph.org), the COVID-19 Grant Program of the CUNY Graduate School of Public Health and Health Policy, and the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under Award Number UH3AI133675 and NICHD Grant P2C HD050924 (Carolina Population Center).

Data Availability

The dataset contains sensitive information and is not publicly available. However, it could be made available on reasonable request, with approval from the IRB at the City University of New York.

Code Availability

All analyses were conducted using SAS. SAS code could be made available from the first author (AMP) on reasonable request.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics Approval

This study was approved by the Institutional Review Board at City University of New York.

Consent to Participate

All participants provided informed consent.

Consent for publication

Not applicable.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The dataset contains sensitive information and is not publicly available. However, it could be made available on reasonable request, with approval from the IRB at the City University of New York.

All analyses were conducted using SAS. SAS code could be made available from the first author (AMP) on reasonable request.

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