COVID-19 Stressors and Maternal Mental Health in Georgia, United States: Sources, Effects, and Recommendations

Setting, Sampling, and Data Collection

Study participants were pregnant and postnatal women aged 18 or older living in Georgia, US, during the COVID-19 pandemic. A mixed-methods cross-sectional design was used to collect data across eight domains using Qualtrics. Study participants were informed about the study through social media platforms such as email, WhatsApp, Facebook, and LinkedIn, as well as through iCollege, the Georgia State University learning management platform. Those who volunteered to participate in the study completed a one-time 10-minute online survey administered through Qualtrics. Study participants gave their consent by completing the survey. No personally identifiable information was collected. Data collection began in January 2023 and ended in May 2023. The study was approved by the GSU Institutional Review Board. This paper followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Variables and Measurement

The study questionnaire comprised 15 multiple-choice and open-ended questions and focused on eight domains. The maternal status domain focused on whether participants were pregnant or had a baby during COVID-19, how far along the pregnancy was at the time of survey completion, and how many children they had. The mental health conditions domain focused on the mental health conditions experienced by participants before and during the pandemic, whereas the sources of stressors domain focused on possible sources and events that triggered mental health stress. The stressor effects domain focused on the outcome of stressors that participants experienced during COVID-19, and the coping mechanisms domain focused on how participants coped with the mental health conditions they experienced. With the recommendations domain, participants provided their opinions on what should be done to protect the mental health of pregnant and postnatal women during a pandemic or health emergency in the future.

Analysis

Collected data in Qualtrics were cleaned and exported to the Statistical Package for the Social Sciences (SPSS) version 28 and the Statistical Analysis Software (SAS) version 9 for analysis. Univariate and bivariate analyses were conducted for quantitative data. SPSS was used to conduct univariate analysis, and SAS was used to conduct bivariate and multivariate analysis. SPSS and SAS were also used to triangulate univariate analysis results. Missing quantitative data were excluded from the calculation. Qualitative data were manually extracted from the SPSS database, examined for patterns or emerging repeated ideas, and clustered into meaningful segments. Codes were then assigned to the relevant clustered segments using a thematic approach. Doing this captured important, rich data related to the study. The frequency with which a theme occurred was also documented and used to determine which themes occurred most frequently and which occurred least frequently. For the purposes of credibility, all researchers on this study reviewed codes and themes created from the qualitative data collected. Analyzed qualitative data are presented verbatim (in italics) to convey exactly what participants said in explanation to certain questions.

Univariate Analysis

Bivariate Analysis

Using the Chi-square test, we conducted a bivariate analysis to assess the relationship between mental health (dependent variable) and demographics, maternal status, sources of COVID-19 mental health stressors, effects of COVID-19 stressors, coping mechanisms, and recommendations (independent variables). We found a significant relationship (p = 0.0194) between study participants who had a mental health condition before COVID-19 and our independent variables [Table 2]. For study participants who had a mental health condition before COVID-19, 50.0% had anxiety, 33.3% had depression, 80.0% had PTSD, and 7.7% had no mental health disorder before the pandemic [Table 2]. Upon running bivariate analysis between study participants who had a mental health condition during COVID-19 and our independent variables, we also found a significant

relationship (p < 0.0001). All study participants who had anxiety, depression, and PTSD before COVID-19 also had them during the pandemic and more [Table 2]. Before the pandemic, Asian Americans had the most mental health conditions (37.5%), followed by Whites (36.4%), and African Americans (20.0%). No Hispanic had a mental health condition before the pandemic. During the pandemic, most of the study participants who had a mental health condition were White (75.9%), followed by Asian Americans (50.0%), African Americans (25.0%), and only one Hispanic [Table 2]. Of the participants who had a mental health condition before COVID-19, 50.0% had some college education, 25.0% had a 2-year college education, 35.0% had a bachelor’s degree, 27.8% had a master’s degree, and 20.0% had a doctoral degree [Table 3]. Regarding participants who had a mental health condition during the pandemic, 33.3% had a 2-year college education, 78.5% had a bachelor’s degree, 66.7% had a master’s degree, and 50.0% had a doctoral degree [Table 3]. When it came to family income of study participants who had a mental health condition before COVID-19, 25.0% had incomes within the $25,000–49,999 range, 50.0% were within the $50,000–$74,999 range, 66.7% were within the $75,000–$99,999 range, and 33.3% were within the $100,000.00 and above range [Table 3]. The annual income for study participants with mental health conditions during COVID-19 also varied, with 50.0% earning between $25,000 and $49,999, 33.3% between $50,000 and $74,999, 100.0% between $75,000 and $99,999, and 73.3% earning $100,000.00 and above [Table 3]. About a third of the study participants (33.3%) who earned $100,000 and above per year before the pandemic had a mental health condition. This statistic rose to about three-quarters (73.3%) during the pandemic [Table 3]. The number of participants with a mental health condition who belonged to a two-parent home increased from 31.2% before COVID-19 to 69.2% during the pandemic. For maternal status, 33.3% of the study participants with a mental health condition were pregnant before COVID-19. This number rose to 71.4% during the pandemic. Of those with a mental health condition before COVID-19, 32.3% had babies. This percentage rose to 76.7% during the pandemic. Some of the study participants who had a mental health condition before COVID-19 had one child (28.0%), and this increased to 59.1% during the pandemic. The number of participants with two children increased from 40.0% pre-pandemic to 87.5% during the pandemic [Table 3].

Before COVID-19, none of the study participants who had a mental health condition experienced sadness; however, one participant experienced sadness during the pandemic [Table 4]. The percentage of participants with a mental health condition who were worried before COVID-19 decreased from 28.6% to 20.0% during the pandemic. Those who were angry increased from 0.0% before the pandemic to 50.0% during the pandemic, and those who were afraid also increased from 0.0% before the pandemic to 66.7% during the pandemic. Study participants who were not able to relax rose from 50.0% before the pandemic to 100.0% during the pandemic. The experience of poor time management also increased from 57.1% before the pandemic to 100.0% during the pandemic [Table 4].

During COVID-19, 48.0% of the pregnant women had some college education or a bachelor’s degree compared to 52.0% of the participants who had a baby [Table 5], and 25.0% of the pregnant participants had a master’s or doctoral/professional degree compared to 75.0% of the participants who had a baby. This relationship was not significant (p = 0.0950). When we compared the annual income of participants who were pregnant to those who had a baby during COVID-19, we found a significant relationship (p = 0.00114). Over half of the pregnant participants (64.3%) earned an income between $75,000 and $99,999, and 35.7% of the participants who had a baby also earned an annual income within that same range. Among study participants who earned $100,000 and above, 25.7% were pregnant compared to 74.3% who had a baby. Most of the participants who had a baby during the pandemic sought mental health care (81.8%) compared to 18.2% of those who were pregnant. We did not find a significant relationship between pregnant women receiving mental health care during COVID-19 and women who had a baby during COVID-19 (p = 0.0931) [Table 5].

Mental Health Conditions

We found that during the COVID-19 pandemic, the mental health of pregnant and postnatal women in Georgia worsened compared to before the pandemic. Before the pandemic, anxiety was experienced by 21.2% of the study participants, depression by 12.1%, and PTSD by 6.1%. However, during the pandemic, the numbers almost doubled for anxiety (39.4%), more than doubled for depression (27.3%), and increased for PTSD (9.1%). Our findings are consistent with existing literature. According to Howard and Khalifeh (2020), in a state of normalcy, about 20.0% of women experience mental illness when they are pregnant and after they give birth (postnatal).^[16] This percentage increases in times of an external stimulus, such as a pandemic or health emergency. In their study, Ceulemans et al. (2021) also found that most pregnant and postnatal women experienced increased psychological stress during the pandemic.^[17] Lopez-Morales et al. (2021) also noted a pronounced increase in depression and anxiety among pregnant women compared to non-pregnant women as the pandemic progressed.^[18] Pregnant women reported 33.0% of symptoms of moderate and severe depression compared with 10.0% in the non-pregnant population. Data from Europe also reported poorer mental health, such as PTSD, anxiety, and depression, among postnatal women during the first and second waves of the pandemic.^[19,20]

Mental health conditions can have adverse effects (preeclampsia, miscarriage, preterm birth, gestational hypertension, low infant birth weight, and stillbirth) on mothers, fetuses, and children during pregnancy and after childbirth.^[21,22] A systematic review conducted by Chmielewska et al. (2021) revealed that the incidence of maternal mortality, maternal stress, stillbirth, and ruptured ectopic pregnancy was higher during the COVID-19 pandemic than before the pandemic.^[23] Understanding the implications of the COVID-19 pandemic on the mental health of pregnant and postnatal women is crucial to avoiding negative and secondary consequences for mother and child.^[19]

Stressors

Our findings revealed that the mental health of the study participants was affected by several stressors including the fear of getting COVID-19, the possibility of their baby (born and unborn) becoming infected with the virus, social isolation, the inability to visit friends and family and to implement COVID-19 protocols, and the fear of a family member becoming sick. Other stressors included the lack of in-person schooling for children, the loss of employment, and not being allowed to attend in-person visits to healthcare facilities with significant others. These findings align with existing research. Per Zamarro et al., the uncertainty of the impact of the pandemic and vaccination on fetuses and infants, disruptions in birth plans and postnatal care, and reduced access to childcare served as stressors that negatively affected the mental health outcomes of postnatal women.^[24] These researchers also indicated that women who worked in professions such as healthcare and teaching in Georgia were more likely to be exposed to the virus, hence their fear and worry. The closure of schools and childcare facilities led to additional unpaid domestic and childcare responsibilities, which women had to take on in addition to being pregnant or having just had a baby.^[25]

Mortazavi et al. noted that loneliness was a common stressor among pregnant women during the pandemic.^[26] This is because they felt unsupported, lonely, and abandoned as their partners were not allowed to accompany them to the hospital to deliver.^[9,27,28] Some of our study participants felt the same way as they were left to go through pregnancy and childbirth alone during the pandemic. It is a cultural norm in the US, and hence in Georgia, for partners to be present at health facilities during delivery to provide physical and emotional support. Social support and interactions are protective factors against the development of depression and anxiety^[29-32] during pregnancy and the postnatal period and are also predictors of maternal mental health.^[33,34] In their study on the mental health of 3,411 pregnant and 1,799 postnatal women during the pandemic in Europe, Tauqeer et al.,^[20] found that pregnant and postnatal women were very anxious about not having partner support during and after delivery. The lack of partner support during and after delivery may have contributed to heightened anxiety and the worsening of pre-existing mental health conditions among pregnant and postnatal women in Georgia. This finding draws attention to the need for close follow-up of pregnant and postnatal women with pre-existing mental health conditions during pandemics or health emergencies.

Effects

The effects of COVID-19 stressors on the mental health of the study participants were greater during the pandemic. The effects ranged from worry (50%), sadness (42.4%), loneliness (36.4%), difficulty relaxing (31.8%), and fear (30.3%) to being unable to enjoy an important milestone (pregnancy or birth of a child) (27.3%). This finding aligns with existing studies. When examining the physical and mental health of pregnant and postnatal women across the globe, multiple studies found worsening changes in sleep quality and energy levels relative to pre-pandemic levels.^[35-37] In their study on women’s pregnancy and childbirth experience during COVID-19, Keating et al. reported that some women felt less excitement surrounding their pregnancy and antenatal clinic visits due to tight restrictions on partner presence.^[38] Strict restrictions during the initial lockdown added to the concern of pregnant and postnatal women about how fathers would bond with their infants, and who would advocate for or ask questions on their behalf at health facilities.^[38] Based on their study on pregnancy-related stress during COVID-19, Ablow and Sullivan reported that about 75% of postnatal women indicated that the pandemic had an extreme impact on their daily lives.^[39]

Coping Mechanisms

Coping refers to cognitive and behavioral efforts to handle difficult situations. It usually involves looking for alternative solutions to encountered problems and looking for ways of obtaining support to protect oneself and others.^[40] Our study results showed that during the pandemic, some pregnant and postnatal women sought care from mental health professionals to cope with and manage the stressors they experienced, while others did not. Of the participants who received mental health care, 81.0% had babies, and 18.0% were pregnant. Participants who had babies experienced extra stress and thus sought mental health care more than those who were pregnant. In their study on coping strategies for COVID-19 pandemic-related stress and mental health during pregnancy, Badon et al.,^[41] found a negative association between talking to health care providers frequently and higher rates of depression and anxiety, suggesting that this mechanism was ineffective for coping with COVID-19-related stress. This finding was surprising to us, as we thought the converse would be true. Corroborating our thoughts, other literature indicates that seeking mental health care during pregnancy and the postnatal period offers numerous benefits, such as improved maternal health, better pregnancy outcomes, and enhanced mother and infant bonding.^[42] In their study on the psychological impact of COVID-19 on women’s mental health, Ahmad and Vismara found that social support and engaging in regular physical activities using online programs or videos were other mechanisms used by pregnant women to cope with pandemic-related mental health stressors.^[43]

Recommendations

Study participants recommended the use of telemedicine to protect the mental health of pregnant and postnatal women during a pandemic in the future. This is because telemedicine interventions use video calls to provide effective healthcare communication without the use of personal protective equipment and allow partners or family members to be present during antenatal and postnatal consultations. This recommendation is useful as it aligns with the findings of a study, which found the utilization of telemedicine as a satisfactory mechanism for addressing mental health conditions among postnatal women.^[44] Before the pandemic, perinatal telemedicine provided health outcomes comparable with in-person care for conditions such as diabetes mellitus, hypertension, and perinatal depression.^[45] With the onslaught of the pandemic, rapid healthcare infrastructure and modified reimbursement structures were developed, which supported the widespread implementation of telemedicine.^[46] Improving healthcare delivery via telemedicine provided flexibility for pregnant and postnatal women, and may have helped to reduce disparities and improve obstetrical outcomes in the US, including Georgia.^[47]

Study participants also recommended the need for health systems and healthcare providers to provide pregnant and postnatal women with accurate information on resources and how to keep themselves and their babies safe during a pandemic or health emergency. Offering information on coping strategies, mental health resources, and support networks can significantly improve the psychological well-being of this population during a future outbreak.^[48] Sharing information about virtual support groups, online counseling services, and other resources can help pregnant and postnatal women feel less isolated and more connected to their communities.^[49] Knowledge can empower pregnant and postnatal women to make informed choices and decisions about their health and that of their babies.^[50]

Study Limitations

Our study had some limitations. Our sample size could have been bigger. Due to the pandemic, we were only able to recruit through online and social media platforms. This strategy may have excluded women who do not use or have access to social media from participating. The utilization of convenience sampling as opposed to random sampling means that our findings cannot be generalized to all pregnant and postnatal women in Georgia during the pandemic. Regardless of these limitations, our findings represent the voices of pregnant and postnatal women in Georgia during the pandemic.

Key Messages

(1) Global health epidemics often occur without warning. (2) Maternal mental health can be severely impacted during such times, as was evidenced by the COVID-19 pandemic. (3) It is important for local government and healthcare providers to be proactive and put in place mechanisms to maintain mental health during such times.