Pregnant people’s responses to the COVID-19 pandemic: a mixed-methods, descriptive study
==========================================================================================

* Hamideh Bayrampour
* Sukhpreet K. Tamana
* Amelie Boutin

## Abstract

**Background:** Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population.

**Methods:** This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people’s thoughts, feelings and experiences during the pandemic. Participants were recruited using study posters distributed via prenatal care clinics and classes, LifeLabs and social media across the province. We used thematic and descriptive analyses to analyze the data, and we integrated the qualitative and quantitative findings at the interpretation level.

**Results:** The study sample included 96 participants with mean (± standard deviation) maternal and gestational ages of 32 ± 3.92 years and 22.73 ± 8.93 weeks, respectively. Most (93%; *n* = 89) identified as female. Of the participants, 54% (*n* = 50) and 35% (*n* = 34) reported anxiety and depressive symptoms, as measured by the GAD-7 and EPDS, respectively. Overarching themes that emerged from the qualitative data included uncertainty about birth plans and setting, added burden to existing health and social disparities, perceived or projected lack of support or limited support, concerns about early development, and struggle over managing multiple demands. Perceived maternity care needs included mental health support, maintaining prenatal care, frequent and proactive check-ins to build rapport, and recommendations specific to the pandemic.

**Interpretation:** We found that the impact of the COVID-19 pandemic on the pregnant population has been substantial. The findings of this mixed-methods study can be used to help plan informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families.

Pandemics cause extensive social, psychological, economic and political disruptions, and they increase morbidity and mortality.1,2 Analyses of the susceptibility of pregnant people to COVID-19 suggest that they have increased vulnerability as a result of physiologic alterations in the respiratory, circulatory and immune systems, and reproductive hormone changes associated with pregnancy.3 Findings of a systematic review of 19 studies on pregnancy and perinatal outcomes of pregnant people with coronavirus-spectrum infections (including SARS-CoV-2) showed higher rates of preterm birth, miscarriage, preeclampsia, cesarean delivery and perinatal death compared to pregnant people who were not infected.4 In a United Kingdom cohort of pregnant people admitted to hospital with COVID-19 between Mar. 1 and Apr. 14, 2020, 10% needed respiratory support in a critical care setting and the case fatality rate was 1.2%.5 Another study in France showed increased maternal morbidity and preterm birth and a 24.1% need for oxygen support among 54 pregnant people with confirmed or suspected COVID-19 between Mar. 1 and Apr. 3, 2020.6 Among noninfected women, a 2021 systematic review showed a significant increase in stillbirth and maternal mortality during the pandemic compared to before the pandemic.7

Historical data from the 1918 influenza pandemic, severe acute respiratory syndrome (SARS) and other infectious disease outbreaks show that even if pregnant people are not infected, they suffer disproportionately during such outbreaks.8–10 Pregnant people are often vigilant about the health and safety of their fetuses. A pandemic could intensify this apprehension, because poor clinical outcomes among infected pregnant people11 and higher rates of pregnancy loss and preterm births have been reported in pandemics.4,10,12,13 Some medications for infectious diseases can also be harmful to the fetus.3,8 Moreover, media coverage of the mortality and morbidity associated with pregnancy can intensify fear among pregnant people.8

The perinatal population are major users of health care services in Canada.14 Pandemics may alter the capacity of health care systems to support routine health care services, including pregnancy, intrapartum and postpartum care.15 In British Columbia, Canada, following the declaration of a state of emergency on Mar. 18, 2020, most inpatient non-emergency health services and surgeries were postponed, and outpatient services were offered via virtual care when possible.

Given the extent of the COVID-19 pandemic and uncertainty about the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care services both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population.

## Methods

### Design and setting

This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We used a pragmatism framework to conduct the study. In this framework, qualitative and quantitative approaches are considered compatible and the primary emphasis is on the research question.16 This study was reported in accordance with the Consolidated criteria for reporting qualitative research (COREQ) checklist.17

The data for this study were collected as part of the Pregnancy Specific Anxiety Scale (PSAS) study, which was ongoing in BC when the COVID-19 pandemic emerged in Canada. The PSAS study was originally designed to develop a screening tool to assess pregnancy-specific anxiety, and it was implemented in 3 phases. The first case of community transmission of COVID-19 in BC was confirmed on Mar. 5, 2020, and the BC government declared a state of emergency on Mar. 18, 2020. The current study involved adapting phase 3 of the PSAS study and used data collected between Mar. 20 and May 31, 2020. The goal of phase 3 was instrument evaluation and psychometric testing of the newly developed PSAS to establish its reliability and validity.

### Participants

We recruited participants during their pregnancy using study posters distributed in prenatal care clinics and classes (the clinics were identified through Google search), LifeLabs across the province and social media (including Facebook, Twitter and Instagram). Any pregnant person at any gestational age living in BC was eligible to participate.

### Data sources

After signing a consent form, participants completed an online survey to provide quantitative and qualitative data.

#### Quantitative

We collected detailed descriptive information on individual, obstetric and psychosocial characteristics using an online survey in REDCap ([https://redcap.ubc.ca](https://redcap.ubc.ca)). We assessed depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS),18 a widely used, valid and reliable screening tool for perinatal depression; a cut-off score of 10 is recommended for community samples.19 We assessed anxiety symptoms using the 7-item Generalized Anxiety Disorder (GAD-7) questionnaire,20 a valid and reliable instrument developed to screen for generalized anxiety disorder and its severity.

#### Qualitative

As part of the online survey, participants responded to 6 open-ended questions in writing to describe their thoughts, feelings and experiences during the pandemic (Appendix 1, available at [www.cmajopen.ca/content/10/1/E146/suppl/DC1](http://www.cmajopen.ca/content/10/1/E146/suppl/DC1)). The research team developed these questions with the aim of capturing whether and how the outbreak had affected participants’ everyday life; their physical and mental well-being, as well as the well-being of their pregnancy and baby; how they coped; and how their health care provider(s) could support them better during the pandemic. We imposed no word limit on the answer fields.

### Data analysis

#### Quantitative analysis

We described individual, obstetric and mental health characteristics using proportions, means and measures of dispersion calculated using IBM SPSS Statistics version 25.21

#### Qualitative analysis

We used a qualitative descriptive approach22 to analyze qualitative data. This approach is appropriate for addressing health care practice and policy inquiries where researchers stay close to the data to describe and interpret findings in everyday terms. Two female researchers (H.B., S.T.) carried out a thematic analysis23: H.B. is an assistant professor with research experience in qualitative and mixed-methods studies, and S.T. is a research associate with a doctoral qualification in clinical psychology. S.T. also conducted clinical diagnostic interviews with participants over the phone as part of the overall PSAS study after they had completed the online survey.

The analysts open-coded each participant’s input after reading it. Codes were clustered into categories (sub-themes) and then grouped into themes. The themes and categories were formulated to achieve a joint interpretation of the data.

The qualitative data were managed using Microsoft Excel. Analytic rigour (i.e., visibility of research practice and accountability of data analysis)24,25 was ensured by independent analysis of the data by the researchers; by including participants’ reflections and verbatim quotations; and by reporting participants’ characteristics to enable readers to identify the study’s applicability to diverse populations.

#### Integration of qualitative and quantitative components

Integration of the qualitative and quantitative components occurred at the interpretation level by embedding and merging the study findings and conclusions.

### Ethics approval

This study was approved by the University of British Columbia Conjoint Health Research Ethics Board (H21–00489).

## Results

The study sample included 96 pregnant participants with a mean (± standard deviation) age of 32 ± 3.92 years. Gestational age varied between 7 and 40 weeks (mean ± standard deviation 22.73 ± 8.93 weeks; Table 1). All participants (*n* = 96) completed the anxiety and depression questionnaires (EPDS and GAD-7). All participants answered open-ended questions 1 to 4. Eighteen participants did not answer open-ended questions 5 or 6.

View this table:
[Table 1:](http://www.cmajopen.ca/content/10/1/E146/T1)

Table 1: 
Participant characteristics (*n* = 96)

The findings of the qualitative analysis are grouped under 3 overarching themes: responses to the COVID-19 pandemic; participants’ experiences related to the pandemic; and perceived maternity care needs (Table 2).

View this table:
[Table 2:](http://www.cmajopen.ca/content/10/1/E146/T2)

Table 2: 
Summary of themes from qualitative data and representative quotes (Mar. 20 to May 31, 2020; British Columbia, Canada)

### Responses to the COVID-19 pandemic

Two categories emerged from participants’ responses to the pandemic: psychological responses, and responses to pandemic-imposed prenatal care, birth restrictions and protective measures.

#### Psychological responses

Participants reported a wide range of psychological responses to the pandemic: anxiety, grief, mourning, sadness, fear, irritation, nervousness, anger and feeling overwhelmed. Some also reported panic attacks and insomnia. The central subthemes in the psychological responses were anxiety and grief.

##### Anxiety and grief

Participants reported multiple worries, including anxiety about being infected with SARS-CoV-2; transmission of the virus to the fetus; and a lack of clear evidence about the effect of COVID-19 on pregnancy and the developing fetus. Some worries were related to health services, such as the risks associated with a hospital birth and their impact on birth plans; the availability of health services if required; or the inability to take medication during pregnancy if they became ill. Others were related to the social effects of the pandemic, such as being isolated; the effect of social distancing and related measures on overall well-being during pregnancy and early motherhood; the long-term effects of COVID-19 on infants and children; the inability to develop social connections and support systems because of the pandemic; increased child care obligations; reduced instrumental support (e.g., help with child care, meal preparation, errands) because of social distancing and travel restrictions; and the inability to deal with stress and anxiety in conventional ways (e.g., exercise and visiting friends and family). Some reported worries related to job security, unemployment and the inability to accumulate required work hours to be qualified for maternity leave; financial strains; and general anxiety about the future and related uncertainties.

Similarly, quantitative data showed prevalent anxiety and depressive symptoms among pregnant people. Of the participant sample, 54% (*n* = 50) reported anxiety symptoms ranging from mild to severe as measured using GAD-7. Depressive symptoms were reported by 35% of participants (*n* = 34).

Numerous participants identified a sense of loss and grief about losing a “normal” pregnancy experience and expressed irritation that a “normal” experience had been taken from them. Several participants who answered open-ended questions later in the study period described being very tense at the beginning of the pandemic in March, a state that had gradually eased by May.

#### Responses to pandemic-imposed prenatal care, birth restrictions and protective measures

Participants reported the implementation of restrictions related to their pregnancy care, including not being allowed to have a support person during prenatal care or ultrasound visits, or being allowed only a limited number of support people during labour.

##### Loss of support and connections

Participants reported a loss of support during pregnancy or a projected loss of support during labour because of pandemic-related restrictions. They expressed concerns that these restrictions had jeopardized or would jeopardize the quality of their pregnancy and birth experience. Participants often noted that the new restrictions negatively affected the support and connections they had hoped to receive and develop.

##### Loss of control and autonomy

Having limited choices as a result of the restrictions and not knowing what to expect during the birthing process contributed to a sense of loss of control. Some participants commented that uncertainty about the birthing process compromised their sense of control and provoked anxiety. Irritation, anxiety and worry related to the restrictions were a recurring theme. It was evident that the pandemic-imposed maternity care constraints had created additional anxiety for participants, who were already anxious. Some described the effect of these restrictions as “losing some freedom.” Concerns also emerged about an unfriendly and impersonal hospital environment because of personal protective measures.

### Experiences related to the pandemic

The theme of people’s experiences related to the pandemic included uncertainty about birth plans and birth settings; added burden to the existing health and social disparities; perceived or projected lack of support or limited support; concerns about early development; and struggles over managing multiple demands.

#### Uncertainty about birth plans and birth settings

Several participants reported feeling uncertain about the safety of hospitals and expressed fear of giving birth in a hospital because of the possibility of contracting COVID-19. A few participants commented that they were considering home births because of these concerns. Two participants reported that although they had confirmed plans for a home birth, they were still fearful that at some point during labour they might have to be transferred to a hospital.

#### Added burden to existing health and social disparities

Some participants reported anxiety about being infected because of frequent pharmacy or hospital visits related to pregnancy and its complications. Participants with limited resources and new immigrants also reported additional stress and burden. For instance, one participant reported that she did not own a vehicle and had been advised not to use public transit; as a result, she had to walk long distances to attend her prenatal appointments.

#### Perceived or projected lack of support or limited support

Some participants described the expectation of limited support around labour as daunting. They expressed concern about uncertainties related to child care when they went into labour, having a complicated or cesarean delivery and recovery, and whether close family members would be available to support them, considering the restrictions on travel and social distancing. Mothers expecting a second or third child also expressed worries about being overwhelmed while self-isolating and not having support from partners, who may or may not have been able to take time off work for financial reasons.

#### Concerns about early development

Participants expressed concerns about how isolation and social distancing would affect their child. They also reported concerns about their own elevated anxiety during pregnancy and its potential consequences for the developing fetus.

#### Struggles over managing multiple demands

Most participants (over 90%) had a paid job during pregnancy, and some reported stress about multitasking and work–life balance. Several participants were front-line workers or partners of front-line workers; an additional layer of anxiety was evident among these participants.

### Perceived maternity care needs

We asked participants how their health care providers could support them better during the pandemic. Several participants reported that they had found their health care providers to be supportive and understanding. Participants also identified several health care needs, outlined below.

#### Maintaining prenatal care visits

Some participants reported interruptions in their maternity care services, such as cancelled appointments or a reduced number of visits early in the pandemic. They identified a need to maintain their prenatal care visits and for their care providers to provide the latest information about the specific effects of COVID-19 on pregnancy. Several participants also expressed worries about the potential implications of the next waves of the pandemic for their health care.

#### Offering the option of in-person visits

Many participants reported receiving virtual care. Because of less frequent or virtual visits, some participants reported concerns that some health issues might not be identified.

#### Frequent and proactive check-ins to build rapport

Because of cancelled, less frequent or short virtual appointments, some participants reported feeling a lack of connection with their maternity care providers. They also noted that they experienced difficulty in building rapport with their providers through virtual care. They stated that more frequent contact would help them develop relationships with their health care providers, so that they would feel more comfortable during labour. They also noted that the increased availability of their providers for more phone check-ins, answering questions and some proactive check-ins would be helpful.

#### Mental health support

Most participants reported a substantial need for mental health support in the form of “check-ins,” coping advice for pandemic-related anxieties and constraints, and setting up counselling and psychology appointments.

#### Partner engagement

Some participants suggested engaging partners and educating them on how to support pregnant people, particularly because partners were not often allowed during prenatal care or ultrasound visits.

## Interpretation

This study provides insights into the experiences of pregnant people, their responses to the COVID-19 pandemic and their perceived maternity care needs between Mar. 20 and May 31, 2020, in BC. The launch of data collection for the qualitative component just after the World Health Organization had declared COVID-19 to be a pandemic26 enabled us to explore and understand the experiences and responses of pregnant people during the first pandemic wave. Qualitative quotations and quantitative measures of anxiety symptoms from our sample indicated highly elevated anxiety symptoms at the onset of the pandemic. Several participants reported that these anxieties gradually eased as the number of new cases in the community decreased.

In the present study, pregnant people reported multiple stressors related to the pandemic, and 44% reported anxiety symptoms. Previous Canadian community-based studies with similar inclusion criteria reported anxiety symptoms at a rate of 15% to 19%.27 Similar findings of poor maternal mental health during the pandemic have been reported globally.7,28–30 The most dominant psychological responses in our study were anxiety and grief, indicating that mental health support, consultations and interventions should be focused on these issues.

Because the pandemic caused major shifts in hospital routines, some participants reported that uncertainty about birth plans and not knowing what to expect during a hospital visit provoked or intensified their anxiety. Providing more tangible information about new hospital birthing processes (e.g., offering a virtual tour of the labour and delivery unit to demonstrate pandemic-related modifications and details on personal protection measures and safety) could help pregnant people become familiar with the new environment, prepare mentally and gain confidence about the safety of a hospital birth. This information could serve to reduce anxiety about the unknown components of the birthing process during the pandemic.

Although restrictions and protective measures have been implemented to protect patients, study participants noted that these measures also imposed additional burdens by limiting access to support and diminishing their sense of control and autonomy during pregnancy and the birthing process. Data from previous pandemics have shown that outbreaks can jeopardize the capacity of health care services in general.15 There is some emerging evidence suggesting a potential increase in labour interventions among people with COVID-19.4,13 In a recent systematic review of 6 studies of 51 pregnant people diagnosed with COVID-19, almost all of them had a cesarean delivery, frequently before term, and without any clear indication for surgery. Although COVID-19 may be associated with spontaneous preterm birth, it has been suggested that the increased risk of preterm birth is a consequence of elective interventions carried out as a precautionary measure.13 Early in the pandemic, some hospitals adopted policies that could have increased labour interventions.31,32 However, a 2021 systematic review did not find an overall change in labour induction and cesarean delivery rates during the pandemic among noninfected pregnant people.7

Many participants expressed concerns about their babies and whether social isolation would affect early development. Although evidence about the effect of pandemics on child development is scarce, disaster studies show that adverse changes in maternal mental health after a disaster strongly influence child development33 and affect the early development of children to a greater extent than the disaster itself.34 Participants also reported concerns about how their own mental health challenges and stresses related to the pandemic would influence the growth and development of their fetus. There is evidence showing that poor perinatal mental health is linked to higher rates of low birth weight and preterm birth,35–37 as well as poor cognitive, behavioural and psychomotor development and mental health problems in children.35,38–42 Further research is needed to elucidate the impact of this pandemic and associated social distancing on short-term and long-term developmental trajectories.

### Limitations

This study had several limitations: it was a small study conducted in a single geographical area, and the findings might be applicable only to settings with a similar outbreak intensity. Findings were based on a convenience sample, so there is a possibility of selection bias. We did not collect the COVID-19 status of participants. We measured anxiety and depressive symptoms using self-reported screening tools; findings do not indicate a diagnosis of these mental health conditions. The open-ended questions were developed by the research team; no pilot study using these questions was conducted. The survey was not anonymous. Most of the participants were well educated, white and partnered; these characteristics could have limited the transferability of the findings. We have provided details of the participants’ characteristics to enable readers to determine the applicability of our study findings to their populations.

### Conclusion

In the present study, we found that the impact of the COVID-19 pandemic on the perinatal population has been substantial. The findings of this mixed-methods descriptive study provide some insights into the effect of the pandemic on this population and can help in planning informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families. Further research is required to understand the short- and long-term physical, psychological and developmental effects of the COVID-19 pandemic on the perinatal population.

## Footnotes

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** Hamideh Bayrampour conceptualized the study, acquired, analyzed and interpreted the data and drafted the manuscript. Sukhpreet Tamana acquired, analyzed and interpreted the data and revised the manuscript for important intellectual content. Amelie Boutin contributed to the interpretation of data and revised the manuscript for important intellectual content. All authors approved the final version of the manuscript for publication and agree to be responsible for its content.

*   **Funding:** The original Pregnancy Specific Anxiety Scale study was funded by the Canadian Institutes for Health Research. There was no funding source for this specific substudy.

*   **Data sharing:** Data are not publicly available.

*   **Supplemental information:** For reviewer comments and the original submission of this manuscript, please see [www.cmajopen.ca/content/10/1/E146/suppl/DC1](http://www.cmajopen.ca/content/10/1/E146/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/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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