Introduction Symptoms of depression, anxiety, and stress in pregnant women are generally highest in the first trimester and then decrease throughout pregnancy, reaching their lowest point in the postpartum period. Pregnant women are a high-risk population for mortality and mental health symptoms due to COVID-19. However, the extent to which the chronic stress of the COVID-19 pandemic alters the trajectory of depression, anxiety and stress symptoms in pregnant/postpartum women is unknown.
Methods Women (N=127) who were pregnant or who had given birth less than one month prior were recruited via online advertising during the COVID-19 pandemic. Participants were assessed up to three times during the pregnancy and at 1-month postpartum for depression (Edinburgh Postnatal Depression Scale), anxiety, and stress (Depression, Anxiety, and Stress Scale-21). Random intercepts models examined symptom change over time as well as predictors of elevated postpartum psychopathology.
Results On average, women completed their surveys at 8.5 weeks (first trimester), 21 weeks (second trimester), 32 weeks (third trimester) and 7-weeks postpartum. Women reported mild-moderate levels of depression, anxiety, and stress throughout pregnancy. There was a significant change in symptoms of depression and anxiety over time which was best represented by a quadratic rather than linear trajectory: symptoms increased until week 23–25 and then decreased. Stress levels remained consistently elevated over time. Higher symptom levels at 1-month postpartum were predicted by younger age, lower social support, and worry about going to a healthcare facility. Change in routine due to COVID-19 was not predictive of symptom trajectory from pregnancy to postpartum.
Conclusions During COVID-19, symptoms of depression and anxiety increased from early to mid-pregnancy but then declined slightly while stress levels remained elevated. Observed reductions in symptoms were small. Given the substantial persistent impact of perinatal distress and poor mental health on maternal and fetal health, providers should be aware of heightened levels of these symptoms in pregnant women during large-scale external health stressors such as COVID-19, and should implement screening procedures to identify and appropriately intervene with at-risk women.
Pregnant and postpartum women are at high-risk for morbidity, mortality and increased symptoms of poor mental health due to COVID-19 (American College of Obstetricians and Gynecologists, 2021; Westgren et al., 2021). Multiple studies have found higher levels of depression, anxiety and stress in pregnant and postpartum women during the pandemic than were reported prepandemic (Khoury et al., 2021; Layton et al., 2021; Lebel et al., 2020). For example, in a sample of over 1000 women across the U. S. surveyed in spring/summer of 2020 (during the pandemic), 36% of pregnant or postpartum women reported symptom levels indicative of depression, and 22% reported symptom levels indicative of generalized anxiety (Liu et al., 2021a). In comparison, pre-pandemic, 13–16% of pregnant women and 17% of postpartum women had symptom levels indicative of probable major depressive disorder (MDD) and 0.3–5.3% of pregnant women and 5.7% of postpartum women met criteria for generalized anxiety disorder (GAD; Dennis et al., 2017; Shorey et al., 2018; Wilcox et al., 2021). Persistent elevated symptoms of depression, anxiety and stress during pregnancy and the postpartum period pose a serious maternal and fetal health risk (Dowse et al., 2020; Kordi et al., 2017; Roy-Matton et al., 2011; Tegethoff et al., 2011). Given that the COVID-19 pandemic directly affected millions of pregnancies in the United States and abroad and that researchers estimate future viral pandemics or endemics are likely, developing an understanding of pandemic influences on mental health in pregnant and postpartum women is critical (Behl et al., 2022; Telenti et al., 2021).
To our knowledge, this is the first study to model changes in depression, anxiety, and stress throughout pregnancy and onemonth postpartum during the COVID-19 pandemic. Consistent with pre-pandemic and pandemic literature showing a decline in symptoms in late pregnancy and in the postpartum period (Asselmann et al., 2020; Gonzalez-Garcia et al., 2021; Rallis et al., 2014), we found that the trajectory of anxiety and depression symptoms was best represented by a quadratic curve whereby symptoms increased in early pregnancy and then began decreasing around week 25 for depression and week 23 for anxiety. However, even with the overall reduction in symptoms, more than 30% of women reported at least moderate symptoms of anxiety and 19% reported at least moderate depression one-month postpartum, which is higher than pre-pandemic estimates from meta-analyses (Dennis et al., 2017; Shorey et al., 2018). Additionally, the reduction in symptoms over time was small and may not represent a clinically significant change. In contrast to results concerning anxiety and depression, stress levels remained consistently elevated over time, underscoring a persistent impact of the pandemic across pregnancy and the postpartum period.