Abstract
Background: The social isolation and safety measures imposed during the COVID-19 pandemic differentially burdened pregnant and postpartum people, disrupting health care and social support systems. We sought to understand the experiences of people navigating pre- and postnatal care, from pregnancy through to the early postpartum period, during the pandemic.
Methods: In this qualitative investigation, we conducted semistructured interviews with people residing in British Columbia and Alberta, Canada, during the second half of pregnancy and again at 4–6 weeks’ post partum between June 2020 and July 2021. Interviews were conducted remotely (via Zoom or telephone) and focused on the impact of the COVID-19 pandemic on pre- and postnatal care, birth and labour planning, and the birthing experience. We used content and thematic analysis to analyze the data, and checked patterns using NVivo.
Results: We interviewed 19 people during the second half of pregnancy and 18 of these people at 4–6 weeks’ post partum. We identified 7 themes/subthemes describing how the COVID-19 pandemic affected their experiences: disrupted support systems, isolation, disrupted health care experiences (pre- and postnatal care, and labour and birth/hospital protocols), violated social norms (including typical rituals such as baby showers), impact on mental health and unexpected benefits (such as a no-visitor policy in hospitals after the birth, which provided a quiet period to bond with baby).
Interpretation: Pregnant and postpartum people were uniquely vulnerable during the COVID-19 pandemic and would have benefited from increased access to support in both health care and social settings. Future work should investigate maternal and infant/child functioning and behaviour to assess the long-term impact of the pandemic on Canadian families and developing children, with an aim to increase support where necessary.
Pregnant and postpartum people were uniquely challenged by the COVID-19 pandemic.1–4 Not only did they need to access health care, they also had to protect themselves and their fetus/newborn from the dangers of COVID-19 amid a high-stakes landscape fraught with uncertainty. Research investigating the mental health impact of COVID-19 on peripartum people suggests that increased anxiety was commonplace5–7 and that pregnancy-related anxiety increased during the pandemic.8 Lockdown safety measures were particularly challenging; Ceulemans and colleagues9 surveyed 5866 women and found significantly increased rates of anxiety and depression. A meta-analysis suggested that rates of postpartum depression also increased during the pandemic.10
Impaired mental health during pregnancy not only affects maternal functioning but is also linked to fetal health and child outcomes.11 An emerging body of research suggests that maternal health during pregnancy is associated with fetal brain development.12 Lu and colleagues13 found that COVID-19-induced anxiety and stress negatively affected fetal brain development, and Manning and colleagues14 reported that worsening of maternal mental health during the COVID-19 pandemic, especially related to a lack of social support, may explain impaired brain structure and function in 3-month-old infants. Research also suggests that the impact of impaired mental health during pregnancy is associated with a range of child outcomes years later.15 In a longitudinal investigation, Provenzi and colleagues16 showed that increased maternal stress during the prenatal period, paired with low levels of support in the postpartum period, was associated with decreased infant regulation at 3 months post partum. Duguay and colleagues17 found that maternal mental health and well-being during the COVID-19 pandemic, especially poor postnatal mental health, were associated with impaired socioemotional development during infancy.
Given the major challenges associated with the COVID-19 pandemic, and that stress may impair maternal and child functioning, we conducted a study to investigate how the pandemic affected the experiences of pregnant people in general, and how it affected birth preparation and planning behaviours, and pre- and postnatal care experiences.
Methods
Study design
We conducted a qualitative investigation supported by a phenomenologic philosophy with thematic and content analytical methods to better understand the birthing behaviours and experiences of Canadians during the COVID-19 pandemic (Appendix 1, Qualitative framework, available at www.cmajopen.ca/content/11/4/E716/suppl/DC1). We sought to understand the essential experiences of people navigating the birth of a child during a global pandemic. The evolving nature of the COVID-19 pandemic was best captured by continued reflection by the researchers and with vigilance for personal biases and preconceptions. We conducted 2 sessions (1 while participants were in the second half of pregnancy and the other in the early postpartum period) to explore how the pandemic affected the experiences of pregnant and postpartum people in these periods. In reporting our work, we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).18
Setting
Study sessions took place from June 2020 to July 2021. Canada experienced 2 waves of COVID-19 during this time frame (in September 2020 and March 2021). A variety of safety measures, such as requirements to wear protective face masks and show proof of vaccination, along with limits on gatherings and on interprovincial and international travel, were implemented in the provinces of Alberta and British Columbia. Evolving safety measures were also implemented in health care settings as hospitals adjusted their visitor guidelines and policies. Uncertainty around safety measures was especially problematic for pregnant and postpartum people, as these limits directly affected birth planning and support.
Participants
We recruited a convenience sample from June 2020 to February 2021 using a variety of remote methods, including posting recruitment posters at local clinics and cafes in Nanaimo, BC, in the Vancouver Island University Community Newsletter and on social media (Facebook [now Meta Platforms] and Instagram) (Appendix 2, available at www.cmajopen.ca/content/11/4/E716/suppl/DC1). Inclusion criteria were broad, and recruitment aimed to include people in the second half of their pregnancy who were residing in Canada. Facebook and Instagram advertisements were targeted toward women residing in Canada. Some participants were recruited by word of mouth and so had prior knowledge of M.V.M. M.V.M. had met 1 of the participants before their participation in the study. Participants’ names were entered into a draw to win a $100 gift card, and 1 name was drawn in both of the 2 sessions.
We targeted an initial sample size of 12 participants based on the work of Boddy.19 However, given the evolving nature of the COVID-19 pandemic during the study period, we deemed 12 to be insufficient and continued recruiting until saturation was reached. Two additional potential participants contacted us after saturation, and we decided to include these participants, as safety measures were still evolving at that time.
Data collection
Pregnancy session interviews took place from June 2020 to April 2021, and postpartum session interviews took place from August 2020 to July 2021. We collected limited demographic information, eliciting only age, marital status and parity. To adhere to COVID-19 protocols, all study data were collected remotely. Participants could choose to participate via Zoom or telephone. When participants chose Zoom, their interviews were recorded via the Zoom platform. Telephone interviews were recorded directly onto the researcher’s laptop computer.
M.V.M., who is a mother as well as a research psychologist with experience conducting research with pregnant and post-partum people, developed the interview guide and conducted the majority of the interviews; 3 interviews were conducted by J.F. The semistructured interview guide was developed after review of academic and media accounts of pregnant and postpartum people’s experiences during the COVID-19 pandemic. The interview guide was developed without team consensus, and the questions were not piloted. The guide was by design simple and straightforward (Appendix 3, available at www.cmajopen.ca/content/11/4/E716/suppl/DC1).
Notes were taken during and immediately after the interviews. These notes primarily highlighted especially representative quotes or comments. The interviews were transcribed manually by the research team.
Written consent was obtained before the pregnancy session, and verbal consent was obtained before the postpartum session.
Data analysis
Six coders (M.V.M., E.J.-E.F., J.F. and 3 research assistants) worked in teams of at least 2 to code the interviews using thematic and content analysis. Each coder created their own code summary sheet, after which the coders came together to discuss specific codes and to collaborate in order to reach consensus (Appendix 1, Example of the coding process). To promote trustworthiness, 1 of the 2 team leaders (E.J.-E.F. and M.V.M.) led these discussions, and all team members tracked their decision-making processes for auditability.20 We ensured that each step of the process was reflexive and collaborative; themes evolved as the study continued. E.J.-E.F. and M.V.M came to consensus on the final themes (Appendix 1, Aspects of qualitative rigour). We imported the finalized coded interviews into NVivo to evaluate the accuracy of our categories and themes. Participants were given the option of reviewing the transcriptions, but no participants opted to do so, nor did they provide feedback on the findings.
Ethics approval
The Vancouver Island University Research Ethics Board approved this study (no. 100647).
Results
Semistructured interviews were conducted with 19 participants during the second half of pregnancy (mean 29.52 wk, range 17–39 wk) and with 18 participants at about 4–6 weeks post partum (mean 5.94 wk, range 2–21 wk). One participant did not continue, as she was busy with her baby. We were contacted by 1 person living outside of Canada and 1 Canadian living abroad; these participants were excluded as they did not meet the inclusion criteria. Participant demographic characteristics are presented in Table 1.
Interviews took, on average, 30 minutes.
Seven themes/subthemes emerged regarding how the COVID-19 pandemic affected support in the health care and social domains, as well as resiliency, adaptability and vulnerability in caring for a newborn during the pandemic: disrupted support systems, isolation, disrupted health care experiences (pre- and postnatal care, and labour and birth/hospital protocols), violated social norms (including typical rituals such as baby showers), impact on mental health and unexpected benefits.
Disrupted support systems
Both pregnant and postpartum participants experienced reduced support at all levels: health care, family, friends and communities. This occurred for a variety of reasons, including travel safety measures, which limited family members’ ability to attend the birth, and safety measures regarding gathering in the community. In many cases, participants were not able to bring anyone to their prenatal appointments, including their husbands/partners, owing to COVID-19 safety guidelines. Many participants communicated empathy over their partner’s disconnected experience. In addition, relaying health care information to their partners was often challenging. Many participants were especially worried about whether the baby’s father would be permitted inside the hospital and whether they would have to give birth alone (Table 2, quotations 1–3).
Travel safety measures imposed by governments around the world in response to the pandemic disrupted the participation of key support people. For example, some participants described how their mother or sister might not be able to attend (Table 2, quotation 4). Many participants reported collaborating with their family to practise quarantining before family members visited the baby. The changing safety measures at the provincial, national and global levels increased stress and anxiety.
Isolation
Social isolation resulting from COVID-19 safety measures was a common thread throughout the pre- and postnatal interviews. Many prenatal support groups were cancelled or converted to online platforms. Participants missed the connection, support and knowledge they would have obtained from taking part in prenatal groups. Online classes were useful in terms of increasing knowledge, but the format is not conducive to relationship-building. Similarly, many postpartum participants discussed a sense of missing the shared experiences with other new mothers, as they were not able to access programs such as Strong Start or postnatal yoga. For many participants, postpartum isolation embodied a strong sense of grief and loss (Table 2, quotations 5–8).
The typical loneliness associated with the early postpartum period21 was considerably worsened during the pandemic. A lack of postnatal programs, social safety measures and distancing, and, perhaps most poignantly, intrafamilial conflict led to prolonged and extensive social disconnect. Participants’ adherence to safety measures and keeping their social “bubble” small resulted in fractured community ties and feelings of isolation (Table 2, quotations 9 and 10). In speaking about wanting to keep her infant safe from infection, 1 participant described a particularly challenging experience with her father (Table 2, quotation 11).
The pandemic even complicated everyday tasks. Many participants discussed feeling judged for their pregnancy while out grocery shopping, which exacerbated the sense of disconnect (Table 2, quotation 12).
Disrupted health care experiences
Pre- and postnatal care
Participants commonly reported fewer prenatal appointments, remote prenatal appointments, or both.8,22 Participants described the infrequency of appointments and lack of face-to-face meetings as impairing the development of the relationship with their health care team. Although some participants reported that the virtual meetings were convenient, this format did not work for everyone and, in some cases, may have limited participants’ ability to speak freely (Table 2, quotations 13 and 14).
Some participants noted that they were taking their own measurements and performing self-checkups. Not receiving feedback, updates or reassurance on the progression of their pregnancy was stressful. Fewer or remote appointments continued through the postpartum period. This left a few participants who were recovering from the birth (e.g., cesarian delivery) with limited supervision. For example, 1 participant was given a baby scale and told to weigh the baby themselves (Table 2, quotation 15). Some participants reported that the pandemic-induced changes contributed to an overall sense of isolation (Table 2, quotation 16). Many participants expressed concern and sadness for first-time mothers.
Labour and birth/hospital protocols
The pandemic coloured all aspects of labour and birth. The hospital safety protocols were described by most participants as frustrating, repetitive and time-consuming (Table 2, quotation 17). For example, 1 participant ended up late for her scheduled cesarian delivery as she had to wait in line to be screened, and another was subjected to COVID-19-related protocols while in active labour (Table 2, quotations 18 and 19).
Although the importance of social supports during labour and birth were recognized early in the pandemic,23 many hospitals limited the support to 1 person. Consequently, some participants were put in the difficult position of needing to choose among their husband, mother, sibling and doula. As the positive impact of doulas on birthing experiences and on both maternal and infant outcomes has been documented,24,25 choosing husband/partner over doula may have resulted in longer and more complicated birthing experiences.
Many participants noted that, once they were in their room at the hospital, they were not allowed to leave. The participants’ partners were allowed to come and go only once per day. Being stuck in a hospital room after birth was described as a negative experience (Table 2, quotation 20).
Participants who experienced complications were especially vulnerable, as the COVID-19 safety measures often limited support when it was needed most. For example, 1 participant’s family was not able to fly in to visit, nor were her friends able to provide in-person support; she spent the holidays alone in an apartment near the neonatal intensive care unit. She described the safety measures for accessing the unit as both necessary and challenging: for instance, only 1 person was allowed to visit at a time, which meant that new parents could not spend time together with their infant (Table 2, quotation 21). Complications during pregnancy and the postpartum period heightened COVID-19-induced isolation and increased maternal stress.
Violated social norms
Participants shared how bringing a child into the world during a global pandemic was an uncomfortable experience (Table 2, quotation 22). One participant observed that there was “a decreased feeling of specialness” around pregnancy. Social events such as baby showers were complicated and often marked by perceived stigma. One participant reported that her baby shower was met with resistance from friends and family. Some participants transferred their baby showers online and found creative ways to connect, whereas others talked about disappointment and disconnect (Table 2, quotations 23 and 24).
Impact on mental health
Many participants expressed worries about health, vaccines and their baby’s development during and after the pandemic. Financial concerns were also reported: participants shared how being forced to take time off work because of COVID-19 set them in a financial deficit, and some discussed uncertainties around receiving the Canadian Emergency Response Benefit, employment insurance or maternity leave (Table 2, quotations 25 and 26).
Worries about COVID-19 in general, the risk of infection and how COVID-19 would affect the development of their child were common (Table 2, quotations 27–29). Concerns included the impact of lack of socialization and use of masks on social development (Table 2, quotation 30), as well as the affect of extensive use of sanitizing measures and masks on the immune system.
There was a definite shift in tone, from uncertainty and anxiety, toward apathy and weariness, from earlier as opposed to later in the pandemic (Table 2, quotations 31 and 32).
Unexpected benefits
Despite the extensive negative impact of the COVID-19 pandemic, there were unexpected benefits. For example, lock-down measures forced participants to take time off work, spend time with their partner, engage in self-care and rest. Many participants reported that the no-visitor policy at the hospital provided an opportunity to recover and connect with their baby after the birth (Table 2, quotations 33 and 34).
Interpretation
This study shows that the impact of the COVID-19 pandemic on pregnant and postpartum people may be understood as an accumulation of losses and unmet expectations, with both major stressors, such as reduced health care and support, and minor stressors, such as cancelled baby showers. Our results support past research suggesting that public health policies designed to reduce the spread of SARS-CoV-2 had especially negative consequences for pregnant and postpartum people1–9,26,27 and that the isolation and social disconnect (from family, friends, health care and community) were the primary drivers of the negative impacts. Our findings support existing research suggesting that this isolation had a negative impact on mental health.28
We found that, although pregnant people were faced with many challenges during the pandemic, including economic uncertainty and fewer health care appointments, the most pressing and commonly reported concerns centred around the logistics of the birth itself. In keeping with previous studies,26,27 whether their partner/husband could be present was a pervasive concern for our participants. People who opted for a home birth were not insulated, as the home health care team also limited who could be present. Our findings support previous research suggesting that the safety measures around limiting support people increased stress.26,27 Families who experienced complications were especially vulnerable,26 as the COVID-19 safety measures often limited support when it was needed most. In future pandemics, special exceptions in the health care setting for pregnancy and birth that allow for the presence of at least 2 support people should be considered, given the bulk of evidence showing negative outcomes associated with stress for pregnant people in terms of decreased mental health4–11 and negative impact on the developing fetus.12–16 However, many participants reported that the no-visitor policy at the hospital provided an opportunity to connect with their baby after the birth. Past research suggests that limiting visitors may, in some cases, facilitate bonding between the newborn and the parents.26,27,29
Our results support previous research suggesting that financial concerns were important considerations.30 Our findings are also in keeping those of Cameron and colleagues,31 who suggested that households with fewer resources were more negatively affected by financial strain. Special financial aid for pregnant people and their families may reduce stress and improve outcomes during a pandemic.
Our findings highlight how the challenges posed by the COVID-19 pandemic changed from pregnancy to the postpartum period. Whereas the issues reported during pregnancy were largely uniform, tangible and concrete (for example, who can attend the birth? Where, and with whom, will my older child(ren) be?), isolation was the dominant challenge in the postpartum period. Paradoxically, in the case of obstetric complications, COVID-19 was at once irrelevant — as in the case of 1 new mother who reported that she had been concentrating on her baby and recovery, and had not thought about COVID-19 at all — to COVID-19’s becoming paramount, as in the case of a family for whom the safety measures coloured each interaction with their infant. Worry and guilt over their infant’s isolation were common, and keeping the baby safe from exposure to COVID-19 was a major concern, which, in some cases, was a dramatic shift in perspective from the pregnancy sessions and, in others, caused conflict that increased the sense of isolation.
To support postpartum people and their newborn, we are faced with a difficult challenge: how do we keep the mother and newborn safe from infection while providing space for in-person connections that would mitigate the negative mental health impact of isolation? Creative solutions such as the use of wearables (e.g., hats, backpacks) to ensure physical distancing,32–33 the use of a mix of remote, virtual reality and face-to-face delivery methods,34 and the careful use of screening protocols and barriers35 were found in education and work-place settings during the pandemic. Using these strategies in the early postpartum period could help to support new mothers and their families. Given that we interviewed participants during the second half of pregnancy and again in the early postpartum period, our findings may also inform strategies during future pandemics.
Limitations
As our small sample showed considerable individual variation in the impact of the COVID-19 pandemic, it is difficult to gauge the transferability of our results. The fact that the interview guide was not piloted and was developed independently by 1 investigator may limit its construct validity and further limit the interpretability of our findings. We noted that sessions later in the postpartum period were marked by a greater sense of isolation; earlier sessions often focused on healing and care of the baby. A third postpartum session (at 4–6 mo post partum) may have more accurately captured how the pandemic increased the isolation of postpartum people. Finally, there is the potential for social desirability bias: although M.V.M. informed participants that there were no right or wrong answers, and that the study was seeking to understand their experience, participants may have been influenced in their answers or unconsciously influenced by the interviewer.
Conclusion
Given the high stakes of maternal mental and physical health during the peripartum period, especially in terms of later infant and child functioning, providing sufficient support to pregnant and postpartum people during times of social upheaval such as the COVID-19 pandemic should be considered an urgent priority. Strategies to increase support in health care and social settings, especially during the postpartum period, would have eased the burden of the COVID-19-induced isolation and stress. Future studies should investigate the long-term impact of the COVID-19 pandemic on child and family outcomes.
Acknowledgements
The authors acknowledge 3 participating investigators, Stephanie Altenhof, Natasha Ladouceur and Kelly Zhang, who conducted content and thematic analysis. They also thank the participants, who shared their time and experiences so generously during the COVID-19 pandemic.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
Contributors: Marla Morden conceived of and designed the study, and obtained the data. Marla Morden and Emma Ferris analyzed the data, with contributions from Jenna Furtmann. Marla Morden and Emma Ferris interpreted the data and drafted the manuscript. All authors revised the manuscript critically for important intellectual content, approved the final version to be published and agreed to be accountable for all aspects of the work.
Funding: This study was funded by Vancouver Island University Scholarship, Research & Creative Activity funds (VIURAC COVID-19 special funding).
Data sharing: Given the personal nature of the qualitative data, the data are not publicly available.
Supplemental information: For reviewer comments and the original submission of this manuscript, please see www.cmajopen.ca/content/11/4/E716/suppl/DC1.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
References
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