Giving birth during a pandemic: From elation to psychopathology

Int J Gynecol Obstet. 2021;00:1–9. | 1wileyonlinelibrary.com/journal/ijgo 1 | INTRODUCTION Postpartum brings about many transformations in a woman's life: changes in hormones and in the brain, as well as social and psychological modifications. One major change takes place in the brain: to ensure the survival and care of the newborn, the brain increases its functional and structural plasticity.1 As a result, it has been discovered that the parts of women's brains related to the detection of threats, as well as emotional recognition, are more active in the postpartum period.2 These adjustments in the brain are associated with emotional transformations, which make postpartum women more susceptible to psychological alterations. Postpartum is thus a critical period for the detection of such changes and for the prevention of psychopathological disorders.3 Received: 27 May 2021 | Revised: 10 June 2021 | Accepted: 28 June 2021 DOI: 10.1002/ijgo.13803 CLINICAL ARTICLE Obstetrics Giving birth during a pandemic: From elation to psychopathology Jose A. PuertasGonzalez1,2 | Carolina MariñoNarvaez1 | Borja RomeroGonzalez3 | Maria Isabel PeraltaRamirez1,2 This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics 1Mind, Brain and Behaviour Research Center (CIMCYC), Granada, Spain 2Personality, Assessment and Psychological Treatment Department, Faculty of Psychology, University of Granada, Granada, Spain 3Psychology Department, Faculty of Education, Campus Duques de Soria, University of Valladolid, Valladolid, Spain Correspondence Borja RomeroGonzalez, Psychology Department, Faculty of Education, Campus Duques de Soria, University of Valladolid, Calle Universidad, s/n, 42004, Spain. Email: [email protected] Funding information Ministry of Economy, Knowledge, Business and University of the Junta de Andalucía, Grant/Award Number: ACTS229UGR18; European Regional Development Fund (ERDF); Spanish Ministry of Science, Innovation and Universities, Grant/Award Number: 18/00617 Abstract Objective: To compare the postpartum psychopathological symptoms of women who gave birth before the pandemic with those who gave birth during the pandemic. Methods: A total of 212 women participated in the study, of which 96 gave birth before the pandemic and 116 during the pandemic. Psychopathological symptoms, postpartum depression, perceived stress, and resilience were evaluated. Results: Women who gave birth during the pandemic had higher scores on somatization, obsessions and compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, and psychoticism. In addition, perceived stress was the common predictor of an increase in these symptoms. Conclusion: Postpartum is a complicated period in a woman's life. Many psychological adaptations take place and women may be subject to psychological alterations during this period. In addition, women who gave birth during the COVID19 crisis may show greater psychological vulnerability, due to the specific situation experienced during the pandemic. The COVID19 pandemic may have played a role in the increase in psychopathological symptoms after childbirth. Detecting possible symptoms postpartum plays a crucial role, because it allows intervening and preventing the development of psychopathologies. KEYWORDS anxiety, COVID19, depression, postpartum, psychopathology, stress 2 | PUERTASGONZALEZ ET AL. In addition, it has also been found that before delivery, pregnant women show more symptoms of somatization, phobic anxiety, or paranoid ideation than nonpregnant women.4 These results suggest that mothers possibly undergo some form of “psychological vulnerability” both during pregnancy and postpartum.1 In a similar line, other studies have shown that events experienced during pregnancy and postpartum may be the precursors of more serious diseases.5 Traumatic or unusual experiences, such as the current global COVID19 pandemic, may encourage the development of psychological disorders. In the light of this historical event, the psychological impact of the crisis on the population has been an object of study. It has been observed that, due to fear of contagion, the symptoms of anxiety and levels of stress have considerably risen among the population.6 In the case of pregnant women, higher levels of stress, anxiety, and depression have been found as a result of being exposed to the stressful ordeal of living through a pandemic.7 In the same way, various studies have explored symptoms of postpartum depression in women who gave birth during the pandemic and higher levels of postpartum depression were found.8 However, these studies did not perform an indepth examination of the wide range of psychopathological symptoms that women may present after childbirth. Given the psychological repercussions of both giving birth and experiencing the pandemic, it has become more essential to study the psychological health of women. Therefore, the aim of the present study was to verify the psychological and emotional state of women who gave birth during the pandemic compared with that of women who gave birth before it. The psychopathological symptoms of women who gave birth before the pandemic were compared with those who gave birth during quarantine. Possible variables related to these symptoms were also verified. 2 | MATERIALS AND METHODS 2.1 | Participants A total of 240 women (mean age 33.46 ± 4.35 years) were recruited and consented to take part in the study. Of them, 212 women finally participated in the present study (13 women did not fill in the questionnaire, 10 filled in the questionnaire more than 1 month after delivery, and five women had been diagnosed with one physical or psychological disease in the previous year). The inclusion criteria were as follows: to be of legal age; to have given birth at some point before or after the State of Emergency was decreed in Spain; to complete the questionnaire within the first month after delivery; to read and write in Spanish; and to have an Internet connection. The exclusion criterion was experiencing physical or mental illness at the time of being diagnosed with any of them in the previous year. All participants gave prior consent before being included in the study. Participation was voluntary and the study was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2013) and the European Union Good Clinical Practice Directive (Directive 2005/28/EC). The study protocol was approved by the University of Granada's Human Research Ethics Committee (reference code 1580/CEIH/2020 and reference number 881). 2.2 | Instruments First, sociodemographic and related variables for birth and newborns were collected from participants. In addition, a psychological assessment was performed using the assessment tools listed below. • The Symptom Checklist90Revised (SCL90R).9 This tool measures nine dimensions of psychopathological symptoms (somatization, obsessivecompulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and three global indices of psychological distress. The Cronbach's alpha reliability coefficients of the Spanish version is in the range of 0.67<α<0.94.10 • Perceived Stress Scale (PSS).10 This scale assesses the degree to which people find their lives unpredictable, uncontrollable, or overcharged in the previous month. The Spanish version of the PSS (14 items) showed a high internal consistency at 0.81. • Connor– Davidson Resilience Scale (CDRISC).11 The CDRISC reflects the ability to resist experiences such as change, personal problems, illness, pressure, failure, and feelings of pain. The Cronbach alpha confidence factor for CDRISC10 is 0.85. • Edinburgh Postnatal Depression Scale (EPDS).12 The EPDS is used to assess the risk of postpartum depression. Its reliability, in terms of internal consistency, is acceptable (α = 0.79). In addition, in the group of women who gave birth during pandemic, the following assessment tool was used: Birth Satisfaction ScaleRevised (SBSSR).13 Three subscales measured overall satisfaction with childbirth: stress during childbirth; personal attributes; and quality of care. The instrument presented adequate internal reliability (α = 0.77). 2.3 | Procedure First, before the pandemic, and coinciding with the Gestastress research protocol, women who had just given birth in Spanish hospitals were recruited. These women, who gave birth between March 2019 and February 2020, constituted the group of women who gave birth before the pandemic. The procedure for recruiting these women was as follows: they were informed of the study after giving birth, and those who agreed to participate filled in the informed consent form. At this point, the questionnaires were sent to them online, using Google forms (sociodemographic variables, SCL90R, PSS, | 3 PUERTASGONZALEZ ET AL. EDPS, and CDRISC) and they were given a maximum of 1 month to fill them in, according to the inclusion criteria. Second, after the sudden onset of the pandemic, and following the declaration of a State of Emergency by the Spanish Government, participants continued to be recruited. However, those women who agreed to participate (through the procedure explained above) were included in the group of women who gave birth during the pandemic (from April 1, 2020, to July 1, 2020). This left two groups (women who gave birth before the pandemic vs those who gave birth during the pandemic). The data obtained and the differences between the two groups were analyzed. 2.4 | Data analysis A descriptive analysis (mean ±standard deviation [SD]) was performed of the sample's main continuous variables, of a sociodemographic and obstetric nature. A frequency analysis was carried out for the remaining categorical variables. In order to verify whether there were any significant differences in psychopathological symptoms between women who gave birth before and during the pandemic, a Student ttest was performed. The dependent variables were the scores of the nine main dimensions of the SCL90R and postpartum depression score, and the independent variable was the moment of delivery (before or during the pandemic). Whether the woman was primiparous or not was included as a covariate. Finally, to verify which psychological variables could predict psychopathological symptoms in women who gave birth during the pandemic, various hierarchical linear regression analyses were conducted, the dependent variables being the scores on the SCL90R subscales. The variables related to delivery were included in step 1 (gestational age at birth, whether primiparous or not, vaginal or instrumental delivery, and satisfaction with delivery), and in step 2, the predictive variables were the perceived stress and resilience (PSS, CDRISC) scores. A collinearity diagnosis was performed to examine variable associations. Tolerance greater than 0.3 and a variance inflation factor below 10 indicate the absence of multicollinearity. The analyses were carried out using the SPSS version 26.0 (IBM Corp., Armonk, NY, USA). 3 | RESULTS 3.1 | Sample description The total sample of participants was divided into two groups: the first group consisted of 96 women (mean age 32.96 ± 3.97 years) who gave birth in the prepandemic period; and the second group consisted of 116 women (mean age 33.86 ± 4.60 years) who gave birth during the pandemic. Both groups were found to be even in relation to the main sociodemographic and obstetric history variables. Statistically significant differences were found between both groups, however, regarding whether they were primiparous or multiparous (ꭓ2 = 5.62; P = 0.018) (Table 1). 3.2 | Differences in psychopathological symptoms and postpartum depression between women who gave birth before and during the pandemic Mean comparison analyses showed statistically significant differences between the prepandemic group of women and the group of women who gave birth during the pandemic in most SCL90R subscales, specifically for somatization, obsessions and compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, and psychoticism. In addition, all scores were higher in the group of women who gave birth during the pandemic, notably regarding obsessions and compulsions, presenting clinical scores over 70. The results are shown in Table 2. No differences were found for postpartum depression, with 25 women (26%) displaying depressive symptomatology (score >10 in EPDS) in the prepandemic group, compared to 33 women (28.4%) in the group who gave birth during the pandemic. 3.3 | Predictive psychological variables of psychopathological symptoms in women who gave birth during the pandemic Psychological variables were analyzed as predictors of psychopathological symptoms, using hierarchical linear regression analysis. All models were significant after controlling for variables related to delivery (gestational age at birth, type of delivery, primiparous or not, and satisfaction with delivery). Furthermore, perceived stress was the only predictor variable for the following psychopathological symptoms: somatization; obsession and compulsion; interpersonal sensitivity; anxiety; phobic anxiety; and psychoticism. In the case of depression, resilience was found as a predictor, along with perceived stress. Regarding hostility, the two predictors were perceived stress and being primiparous. These data are shown in Table 3. 4 | DISCUSSION The aim of the present study was to verify the psychological and emotional status of women who have given birth during a pandemic. To do this, it was first verified whether any differences could be found in a range of psychopathological symptoms between women who had given birth before and during the pandemic. A check was subsequently made as to whether birth and psychological variables were related to, or acted as, predictors of such psychopathological symptoms. 4 | PUERTASGONZALEZ ET AL. The results of the present study indicate that women who had given birth during the pandemic presented more psychopathological symptoms than those who had given birth during the prepandemic period, specifically somatization, obsessions and compulsions, interpersonal sensitivity, anxiety, depression, hostility, phobic anxiety, and psychoticism. Some authors have shown that, during this pandemic, women consider postpartum as a period that involves even more challenges than before; this perception can lead to psychological stress and make women more vulnerable to emotional disturbances. It can also reduce their psychological wellbeing.14 In addition, various studies have shown that levels of stress and depression increased during pregnancy as a result of the pandemic.7,15 Moreover, a woman's concerns about the pandemic and everything around her, such as fear of contagion, being alone during childbirth, or possible vertical transmission to the fetus, simply contribute to the development of these symptoms of anxiety.7 Other psychopathological symptoms such as obsessions, compulsions, and phobic anxiety are equally more widespread in the current situation, characterized by excessive hygiene and fear of contagion.16 The latter, coupled with the fact that during postpartum, the likelihood of experiencing obsessions and compulsions increases twofold, could explain the differences found and the growth in symptomatology.17 However, it should be noted that the scores found in the present study exceeded, on average, the 70th percentile. This latter psychopathological dimension thus presented clinical scores, with all its therapeutic implications. As far as somatization is concerned, this increased during pregnancy, due to the complex emotional and physiological processes proper to gestation.4 Although the role of postpartum somatization is currently unknown, it has been found to increase in different samples of the population. Therefore, it would be unsurprising if it was found to increase after childbirth as a result of the pandemic.18 TABLE 1 Description and comparison in sociodemographic variables and obstetric history, in women who gave birth before and during the pandemic.a Before pandemic (n=96) During pandemic (n=116) t/ꭓ2P Sociodemographic variables Age (years) 32.96 ± 3.97 33.86 ± 4.60 0.46 0.13 Nationality Spanish 77 (83.7) 86 (74.1) 2.76 0.09 Immigrant 15 (16.3) 30 (25.9) Marital status Married/cohabiting 91 (98.9) 109 (94) 3.39 0.06 Single/widow 1 (1.1) 7 (6) Level of education No school 1 (1.1) — 1.49 0.68 Primary school 1 (1.1) 2 (1.7) Secondary school 17 (18.7) 20 (17.2) University 72 (79.1) 94 (81) Obstetric information Nulliparous Yes 46 (50) 75 (66.4) 5.62 0.018b No 46 (50) 38 (33.6) Delivery Vaginal 63 (64.3) 77 (66.4) 0.103 0.748 Instrumental 35 (35.7) 39 (33.6) Sex of infant Male 43 (44.8) 59 (50.9) 0.77 0.37 Female 53 (55.2) 57 (49.1) Gestational age (weeks) 39.48 ± 1.34 39.06 ± 1.79 2.77 0.06 Birth weight (g) 3283.39 ± 462.76 3228.19 ± 484.31 0.44 0.39 aValues are given as number (percentage) or mean ± SD, unless otherwise specified. In some variables there are missing values, so N may not correspond to the corresponding one for each group. bSignificance at P < 0.01. | 5 PUERTASGONZALEZ ET AL. Finally, symptoms such as interpersonal sensitivity, hostility, and psychoticism can be explained by the social restrictions imposed on the population.9 The pandemic's side effects include a rise in individualism and loneliness derived from a halt to social relations. These latter side effects may lead to the accentuation of this type of symptomatology.19 In addition, the pregnancy's own evolutionary perspective means that the mother is capable of detecting threats in the environment to protect her infant and will reject anyone outside her “group,” which may exacerbate the symptoms described at the same time.4,20 As far as postpartum depression is concerned, no difference was found between the two groups in the present study. One possible explanation is that this problem presents a high incidence during postpartum anyway, making it unlikely to detect differences in symptomatology.21 Some authors have reported a rise in these symptoms of depression.22 However, the failure to find any differences demonstrates that women are vulnerable to postpartum depression no matter the moment during which it is experienced, and the first signs of the disease must be addressed. Most of these psychopathological symptoms, which were more widespread in women who gave birth during the pandemic, shared a common predictor variable: that of perceived stress. Stress is one of the psychological problems that has increased the most during this pandemic. This is unsurprising, because the unpredictability of the situation added to a sense of low personal control over it, leading to increased levels of stress.23 In addition, other authors have found that during pregnancy, perceived stress is also a predictor of psychopathology.4 Resilience, an important pregnancy variable, equally seems to be a possible predictor and could dampen the severity of psychopathological symptoms.24 This is a significant finding because it makes it possible to focus on the levels of perceived stress when preparing interventions directed towards the psychological health of a pregnant woman and the postpartum stage. A limitation of this study is the fact that the sample was exclusively composed of Spanish women. This restricts the possibility of generalizing the results, as they can only be attributed to women who experienced the pandemic in Spain. Nevertheless, given the pandemic's global nature, similar results are likely be found in other countries. In conclusion, the results of the present study highlight the delicate period women endure around childbirth, and such conditions have been aggravated by a pandemic. The COVID19 pandemic has affected the whole world, and these women, who must go through the important life process of childbirth, have increased psychopathological symptoms. As a result, it has become essential to work on psychopathological symptoms during pregnancy, to alleviate the effects and their exacerbation after childbirth. Especially now, when they live in a world that generates uncertainty and fear. In addition, assessing the perceived stress that women experience constitutes an essential step. Indeed, early detection leads to timely intervention and provides women the support and tools they need to help them cope. ACKNOWLEDGEMENTS The authors thank every woman who participated in the study. They would also like to thank those who fight against COVID19, risking their lives and those of their relatives. This work was supported by the Frontier Project “ACTS229UGR18” of the Ministry of Economy, Knowledge, Business and University of the Junta de Andalucía, cosupported by funds/European Regional Development Fund (ERDF) – A Way to Build Europe. In addition, JAPG has been awarded with an individual research grant from the Spanish Ministry of Science, Innovation and Universities, FPU program (reference number 18/00617). This study is a part of the Doctoral Thesis of J A P - G . TABLE 2 Differences in psychopathological symptoms among women who gave birth before and during the pandemic.a Before pandemic (n=96) During pandemic (n=116) F P S C L− 9 0 - R Somatization 46.54 ± 27.19 59.86 ± 26.84 11.24 0.001b Obsessions and compulsions 46.71 ± 32.43 72.39 ± 28.06 33.52 0.000b Interpersonal sensitivity 40.18 ± 34.87 62.82 ± 32.37 21.92 0.000b Depression 41.47 ± 30.06 66.12 ± 30.36 32.31 0.000b Anxiety 39.74 ± 30.42 62.20 ± 29.68 26.52 0.000b Hostility 42.48 ± 33.04 55.79 ± 32.84 7.79 0.006b Phobic anxiety 40.97 ± 36.01 60.14 ± 36.76 12.05 0.001b Paranoid ideation 40.49 ± 36.31 48.65 ± 36.64 2.53 0.113 Psychoticism 45.33 ± 37.37 57.74 ± 37.14 5.24 0.023c EPDS 7.78 ± 4.75 7.70 ± 5.42 0.000 0.983 Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; SCL90R, Symptom Checklist90Revised. aValues are given as mean ± SD, unless otherwise specified. bSignificance at P ≤ 0.01. cSignificance at P ≤ 0.05. 6 | PUERTASGONZALEZ ET AL. TABLE 3 Hierarchical linear regression analyses for psychological variables as predictors of psychopathological symptoms. βPRsquare Increased Rsquare F Model 1 Dependent variable: Somatization Block 1 Gestational age 0.100 0.281 0.080 0.080 2.345 Deliverya 0.036 0.712 Primiparous −0.012 0.906 S - B S S - R −0.259 0.010 Block 2 Gestational age 0.127 0.127 0.254 0.174 6.022b Deliverya 0.031 0.732 Primiparous 0.026 0.774 S - B S S - R −0.062 0.533 Perceived stress 0.453 0.000b Resilience −0.070 0.413 Model 2 Dependent variable: Obsessions and compulsions Block 1 Gestational age −0.026 0.780 0.079 0.079 2.314 Deliverya −0.038 0.698 Primiparous −0.087 0.374 S - B S S - R −0.295 0.003 Block 2 Gestational age 0.010 0.907 0.285 0.206 7.045b Deliverya −0.039 0.661 Primiparous −0.054 0.543 S - B S S - R −0.074 0.443 Perceived stress 0.503 0.000b Resilience −0.015 0.859 Model 3 Dependent variable: Interpersonal sensitivity Block 1 Gestational age 0.018 0.846 0.106 0.106 3.194c Deliverya 0.135 0.226 Primiparous −0.117 0.165 S - B S S - R −0.279 0.005 Block 2 Gestational age 0.059 0.463 0.306 0.238 9.235b Deliverya 0.137 0.106 Primiparous −0.084 0.320 S - B S S - R −0.041 0.659 Perceived stress 0.542 0.000b Resilience 0.010 0.902 Model 4 Dependent variable: Depression Block 1 Gestational age 0.031 0.741 0.091 0.091 2.695c (Continues) | 7 PUERTASGONZALEZ ET AL. βPRsquare Increased Rsquare F Deliverya 0.100 0.306 Primiparous −0.109 0.266 S - B S S - R −0.272 0.006 Block 2 Gestational age 0.066 0.363 0.464 0.374 15.321b Deliverya 0.089 0.245 Primiparous −0.050 0.512 S - B S S - R 0.011 0.894 Perceived stress 0.653 0.000b Resilience −0.141 0.049c Model 5 Dependent variable: Anxiety Block 1 Gestational age −0.043 0.643 0.087 0.087 2.566c Delivery 0.029 0.521 Primiparous −0.063 0.764 S - B S S - R −0.292 0.003 Block 2 Gestational age −0.009 0.909 0.334 0.247 8.861b Deliverya 0.024 0.815 Primiparous −0.020 0.775 S - B S S - R −0.055 0.554 Perceived stress 0.543 0.000b Resilience −0.068 0.397 Model 6 Dependent variable: Hostility Block 1 Gestational age −0.075 0.417 0.100 0.100 3.004b Deliverya 0.051 0.597 Primiparous −0.218 0.026 S - B S S - R −0.273 0.006 Block 2 Gestational age −0.051 0.547 0.278 0.177 6.786b Deliverya 0.043 0.624 Primiparous −0.177 0.047c S - B S S - R −0.078 0.424 Perceived stress 0.450 0.000b Resilience −0.097 0.249 Model 7 Dependent variable: Phobic anxiety Block 1 Gestational age −0.093 0.329 0.042 0.042 1.179 Deliverya 0.041 0.686 Primiparous −0.027 0.789 S - B S S - R −0.170 0.092 TABLE 3 (Continued) (Continues) 8 | PUERTASGONZALEZ ET AL. CONFLICTS OF INTEREST The authors have no conflicts of interest. AUTHOR CONTRIBUTIONS JAPG: Conceptualization, methodology, formal analysis, writing the original draft, review and editing the manuscript. CMN: Conceptualization, methodology, data curation. BRG: Conceptualization, data curation, formal analysis, methodology. MIPR: Funding acquisition, conceptualization, review and editing the manuscript, supervision. REFERENCES 1. BarbaMüller E, Craddock S, Carmona S, Hoekzema E. Brain plasticity in pregnancy and the postpartum period: links to maternal caregiving and mental health. Arch Womens Ment Health. 2 0 1 9 ; 2 2 : 2 8 9 - 2 9 9 . h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 0 0 7 3 7 - 0 1 8 - 0 8 8 9 - z . 2. Rutherford HJV, Wallace NS, Laurent HK, Mayes LC. Emotion regulation in parenthood. Dev Rev. 2015;36:114. https://doi. org/10.1016/j.dr.2014.12.008. 3. Miller ML, Kroska EB, Grekin R. Immediate postpartum mood assessment and postpartum depressive symptoms. 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